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DD is an 18-year-old female: single and living in an urban-suburban area of the national capital, Muscat. She was brought to the hospital due to a sudden onset of distress. According to the accompanying family, she had been having episodes of disruptive behavior, impaired vegetative functioning and problems fulfilling activities of daily living. When she came out of prolonged sleep, she made irrelevant conversations and had episodes of incongruent crying. These episodes were followed by increased hyperactivity and agitation. She displayed tangentiality marked by exaggerated euphoria.\nDue to the perceived temporality of her distress, the family devised mechanisms within the household to protect her well-being until the erratic behavior had dissipated. The accompanying sibling informed the clinical team that DD appeared to suddenly become disturbed around the second week of the lunar month. The family recalled that her distress occurred almost every month in the last 2 years. On previous occasions, the family invited a traditional healer who ‘diagnosed’ her as being possessed by the jinn. The fact that she had had little insight into her altered state led the family to believe that her altered state of consciousness represented all the hallmarks of spirit possession. During psychiatric consultation, the clinical team noted that her distress receded and this coincided with the onset of menstrual flow. It appeared, therefore, that her symptoms had persisted until the onset of menstrual flow.\nDD was said to have met all her developmental milestones without difficulty. In Oman, individuals require 12 years to complete secondary education. She recalled that her menses began at 12 years old. She was deemed to have been very bright during her secondary school but upon reaching puberty, due to the aforementioned symptoms, she was only able to finish 9 years of formal education. Thereafter, as often is the case in Oman, she stayed within the confines of her extended and polygamous family. She has 5 siblings and no evidence of mental illness in the family.\nA routine urine drug screening was not significant, and neither were her hormonal study, brain CT scan, and EEG. Semi-structured interview, CIDI, did not confirm that she had the core features of manic (F30) and Bipolar affective disorder (F31), schizophrenia and other psychotic disorders (F20, F22, F23, or F25). Rather, DD was deemed to be marked with something akin to manic episode with psychotic symptoms - Manic episode, unspecified (F309)/brief psychotic disorder (F24). The results of her psychometric evaluation are shown in Fig. , conducted when DD was stable.\nHer disturbed behavior receded within 24 h of admission and she was discharged with antipsychotic olanzapine (5 mg) for which she was compliant. During the follow-up visit, she was stable and jovial and had already stopped her medication. The family and DD were given health education on how to adjust her life to accommodate for her predictable distress that occurred every month.
A 28-year-old female presented to a clinic with difficulty hearing, which had been ongoing without change for one year since her hospitalization for hyperemesis status three months post-sleeve gastrectomy. She had no history of ototoxic medications, auditory or physical trauma, or ear surgery, no recurrent history of otitis media or congenital anomalies, and no family history of early-onset hearing loss. During her hospitalization one year prior to visiting the clinic, she was given intravenous (IV) 5% dextrose in half-normal saline due to her five-day history of hyperemesis and starvation ketosis. On day four of hospitalization, she developed new-onset diplopia and gait ataxia. Her exam was significant for horizontal nystagmus and ataxic gait, including difficulty with tandem walking. The remainder of her neurological exam was normal. Her hearing was preserved and she could hear speech and was able to localize a finger rustling bilaterally. Her brain MRI was normal. Laboratory workup revealed a thiamine deficiency (59 nmol/L, with the normal reference range being 70-180 nmol/L).\nHaving met the diagnostic criteria, a clinical diagnosis of WE was established []. Treatment with IV thiamine was initiated (500 mg infused over 30 minutes three times daily for three days followed by 250 mg once daily for an additional five days). Her nystagmus and ataxia improved the following day after treatment initiation. Her thiamine levels corrected after the completion of the thiamine treatment course and she was discharged in a stable condition, with a return to her baseline values after a total hospital course of five days.\nTwo months after hospital discharge, the patient began noticing diminished hearing in both ears. She described increased difficulty understanding speech on the telephone and when not facing the speaker. She also noted that she required an increased volume when watching television. She did not seek evaluation until nearly one year after the onset, stating she was in disbelief that she was having hearing loss given her young age. Her thiamine levels remained within normal limits one-year post-hospitalization (143 nmol/L). On otoscopic inspection, both ears had patent canals and normal, intact tympanic membranes, with easily recognizable landmarks. The tympanograms were normal bilaterally. The audiogram () showed a speech reception threshold of 25 dB HL bilaterally. When presented at 55 dB HL, word recognition was 82% in the right ear and 87% in the left ear. The pure tone averages were 30 dB HL (right ear) and 25 dB HL (left year). This is consistent with a mild and a slight sensorineural hearing loss in the right and left ear, respectively. In the left ear, distortion product otoacoustic emissions (DPOAEs) were present from 1 to 3 kHz and were absent at 500 Hz and from 4 to 10 kHz. In the right ear, they were absent from 0.5 to 10 kHz.\nThe patient was fitted with bilateral hearing aids and subjective improvement in symptomatic hearing loss was reported. Given her unremarkable personal and family history, genetic testing was deferred. She continued with routine vitamin supplementation and close monitoring and her thiamine levels remained within normal limits.
A 54-year-old Caucasian woman was referred to our department with a history of left-sided abdominal pain, lasting about 8 months. No other signs or symptoms were present at the moment of observation. Past medical history revealed no significant medical problems. Hysterectomy for endometriosis had been performed ten years before admission. No history of carcinogenic exposure was reported. At admission physical examination revealed a palpable spleen 4 cm below the left costal margin. No hepatomegaly was noted. Laboratory exams showed no alterations, except for mildly elevated lactic acide dehydrogenase (LDH). Chest X-ray showed a normal mediastinum and lung parenchyma. Abdominal US revealed, in the superior portion of the spleen, multiple target-shaped focal lesions, one of these with a large anechoic fluid-filled area. CT scan showed a large, inhomogeneous mass of the spleen, of 10 × 7 cm in diameter. This mass was isodense, without enhancement after contrast injection, and had low density fluid-filled areas. The liver parenchyma was normal and no evidence of retroperitoneal lymphadenopathy was found. Emergency laparotomy was performed, due to the suspicion of splenic haematoma. Neither obvious metastases nor hepatic lesions or abdominal fluid were found at laparotomy. An enormous mass of superior portion of the spleen was found, with infiltration of left suprarenal gland and of a portion of diaphragm. Due to the local dissemination a splenectomy and left surrenalectomy were performed, along with a partial diaphragm resection, with a free resection margin of about two centimetres. Splenic vessel lymphadenectomy was also performed. There were no postoperative problems and the patient was discharged on 7th postoperative day. Two different Institution was necessary to obtain the definitive diagnosis. Histological examination showed a spleen of 11 × 5 × 5 cm, with a soft dark lesion, of 10 cm diameter, in the upper pole. Gross examination showed no haemorrhage or necrosis. Microscopic examination revealed a non capsulated spindle and polyhedral cell proliferation along with multiple foci of cellular necrosis. Tumor cells, with pleomorphic and atypic vesicular nuclei, showed marked pleomorphism and rare mitotic figures (Figure , ). Immunohistochemistry showed that the neoplastic cells were positive for smooth muscle actin and for h-caldesmon and negative for CD34, calponin, FVIII-associated antigen, S100, EMA and cytokeratin AE1 AE3. There was left suprarenal gland and diaphragm involvement. The examined lymph nodes had no neoplastic infiltration. Diagnosis of locally advanced primary leiomyosarcoma of the spleen was made (Figure ).\nThe patient underwent specific chemotherapic regimen (5 cycles) with epirubicin 90 mg (days 1 and 2) and ifosfamide 2700 mg (days 1 – 5) every 21 days, with no significant adverse reactions.\nActually, 21 months after operation, the patient is alive and totally disease-free.
A 62-year-old male was admitted to the emergency room due to uncontrolled epistaxis and complaining of swelling and tenderness in the right cheek. The patient was receiving warfarin as an anticoagulative measure, having previously suffered a stroke. An examination of the nasal cavity was not possible at the emergency room due to the severity of bleeding. Nasal packing was applied to staunch the bleeding. Two days later, when the nasal packing was removed and endoscopic examination performed, a mass in the middle meatus and bulging of the medial wall of the maxillary sinus were observed (). Computed tomography (CT) and magnetic resonance imaging (MRI) scans revealed a large mass comprised of soft tissue with an ill-defined outline and an irregular peripheral enhancement on the right maxillary sinus. The mass had pushed against the right inferior wall of the maxillary sinus; destroyed the infraorbital foramen; completely destroyed the medial wall of the maxillary sinus; partially damaged the superior, middle and inferior turbinate; and obstructed the entire right nasal cavity. The lateral, anterior, and inferior walls of the right maxillary sinus were focally destroyed and a focal tumor extension was exposed. The mass extended superiorly to some part of the ethmoid sinus but did not involve the sphenoid sinus and frontal sinus ().\nAn endoscopic biopsy revealed a carcinosarcoma with an osteosarcomatous element by Hematoxylin-eosin staining and immunohistochemical stain (). Fluorodeoxyglucose positron emission tomography (FDG PET)-CT was used to evaluate metastasis to adjacent organs. FDG PET-CT revealed the presence of large mass of soft tissues with increased FDG uptake accompanied by bony erosion in the right maxillary sinus. Also, nodular lung lesions with increased FDG uptake in lateral basal and posterior basal segment of right lower lung were observed. CT-guided lung biopsy for metastasis evaluation indicated only chronic inflammation. Hence, the clinical TNM staging of this patient was T3N0M0 (stage III).\nA surgical resection with postoperative chemoradiation therapy was planned and the patient underwent a total maxillectomy on the right side. Examination in the operating room revealed a large tumor filling the nasal cavity, maxillary sinus, and ethmoid sinus. The tumor had eroded through the inferior and medial orbital walls, however, periorbital invasion was not evident. The tumor had also eroded the lateral bony wall of the maxillary sinus. After the surgical resection, frozen biopsies of all margins were grossly clear.\nThe patient's postoperative course was uncomplicated, and he received postoperative radiation therapy with a total dose of 5,580 cGy. However, during the radiation therapy, a mass lesion in the periorbital area was found in an endoscopic examination. The pathology was indicative of carcinosarcoma. As a consequence, wide local excision was performed on the mass and the patient received a full course of irradiation, followed by chemotherapy (Cisplatin+5 fluorouracil+Taxotere). Two months later, the patient developed a massive recurrence infiltrating the orbit, cheek, and the masseter muscle. The patient decided not to receive further surgical treatment or chemotherapy, and was lost to follow-up.
A 45-year-old man with a 3-year history of chronic cough and recurrent hemoptysis and fever was admitted to our hospital. The cough, which became productive, was exacerbated by swallowing of fluids. Fever and hemoptysis had recurred four times, necessitating antibiotic therapy. A chest computed tomography (CT) scan revealed left lower pulmonary bronchiectasis. Consequently, the patient was referred to us for further diagnosis, although his symptoms were relatively stable. Medical history revealed prior occurrence of hyperthyroidism and hypertension but no history of tuberculosis. Upon physical examination, we noted a few coarse rales in the left lower posterior lung but no finger clubbing. The rest of his physical examination was normal.\nMedical examinations revealed normal blood, liver, kidney, and thyroid functions, as well as normal results for tumor markers. Results from sputum cultures and PCR to test for tuberculosis were negative. However, a chest CT revealed bronchial dilatation in the dorsal segment of the left lower lobe (LLL), with a chronic pulmonary abscess surrounding it. The CT indicated the presence of a fistula between the mid-esophagus and the left intermediate bronchus without mediastinitis or lymphadenopathy (). Bronchoscopy revealed mucosal hyperemia and swelling in the dorsal segment bronchus of the LLL, without purulent secretions and no obvious endobronchial lesions or BEF outlet opening. Histopathological analysis of the bronchial mucosa revealed a normal columnar epithelium, with no inflammation, granuloma, or carcinoma. In addition, iodine contrast examination revealed a medium-sized diverticulum at the left lateral aspect of the esophagus, which had developed a fistulous connection with the LLL bronchus (). Esophagoscopy revealed the diverticulum to be 33 cm from the incisors, with a 3-mm fistulous orifice arising from its apex (). Therefore, the etiology of the bronchiectasis and chronic lung abscess was determined to be BEF secondary to esophageal diverticulum. After multidisciplinary consultation, video-assisted thoracic surgery was suggested as the first choice of treatment and endoscopic therapy as the second choice. The patient refused further treatment because of the potential risks and was subsequently discharged. At the 4-month follow-up, the patient again developed pulmonary infection but improved after treatment with antibiotics.
An 84-year-old female with hypertension and hyperlipidemia had had two vessel coronary ACB 18 years ago with an SVG to left anterior descending artery (LAD) and obtuse marginal artery (OM). Patient had redo ACB 8 years ago with a left internal mammary artery (LIMA) to LAD, and SVG to OM, as she was found to have diffusely diseased SVG to LAD and a totally occluded SVG to OM. Recently, she was found to have a mediastinal mass on routine chest X ray which was done for evaluation of cough and fever. Subsequently, CT scan of chest with contrast was done which revealed a large heterogeneous mass measuring 8.1 × 8.4 cm in size, located on left side of the heart with active flow and large clot burden within the mass (). The coronary angiogram demonstrated a patent LIMA to LAD and patent SVG to OM. A 2 × 3 cm aneurysm was found on injection of another SVG, presumed to be the old SVG to OM, without any distal flow into any native vessel (). The length of the SVG from aorta to aneurysm was 4 cm which was diffusely diseased. A diagnosis of aneurysm of SVG was made. The discrepancy in the aneurysm size between CT scan and angiogram highlights the importance of CT scan in assessing the exact size of aneurysm.\nThe decision was made to occlude flow to the aneurysm due to the risk of its rupture, which is associated with high mortality and morbidity. The SVG feeding the aneurysm was selectively engaged with a 7 French JR4 guide catheter. A standard 0.35 inch Glide wire (Terumo Medical Corporation) was advanced into the aneurysm over which a 5 French Glide catheter was placed at the origin of the aneurysm. The glide wire was removed and an 8 × 5 mm Cook Tornado Embolization coil was deployed. A total of five coils were deployed more proximally in the SVG (). Angiography demonstrated complete cessation of flow into the aneurysm (). The patient was discharged the next day without any complications.
The reported case involves a 49-year-old female patient who had experienced chest tightness for one year. She had untreated familial vitiligo since childhood, and received one-time PAAG injection for breast augmentation 20 years ago. The dosage and the initial injection plane were unknown. Except familial vitiligo, the patient had no other significant past medical history or family history of cancer. And the patient did not smoke or drink alcohol. A few months after the operation, the PAAG began to spread to abdominal regions. Specifically, it was detected in the infraclavicular, subcutaneous tissue of right thoracic wall, perineum, and left side of the upper back. In addition, the skin and soft tissues adjacent to the areas invaded by PAAG became harder and formed numerous hard lumps, especially in the breasts. However, she reported no fever, pain or discomfort. Due to shame and fear, she did not seek medical advice for 15 years. In 2015, she learnt through the Internet of the dangers associated with PAAG and sought medical advice from a physician in November, 2015. She was then hospitalized in the Chinese Academy of Medical Sciences Plastic Surgery Hospital. Chest and abdomen MRI T2-weighted sequence images showed the presence of PAAG gel in many places, including the chest and abdomen wall (Fig. ). In the chest, it was present in subcutaneous tissue and breast gland. Needle biopsy requested by her excluded the possibility of malignant lesions, scleroderma or granuloma. The patient refused to be operated because of high surgical cost, and complications, especially delayed wound healing.\nDuring the subsequent four years, she experienced gradual deterioration of breast contracture and chest tightness accompanied with mild breathing difficulties. The patient visited our plastic surgery department seeking a less invasive treatment option. Physical examination revealed malformation of the anterior trunk and hardening of the chest wall. Different lump sizes were detected over the right clavicular region and the bilateral arch of rib. Lumps were also detected in nearly the entire anterior abdomen, excluding the 12 × 14 cm oval area around the navel, and an 11 × 4 cm oval area on the left lower back (Fig. ).\nPathological examination of the skin showed that the fibrous tissue hyperplasia together with hyalinization in dermal and skin appendages were diminished significantly (Fig. ). The breast surgical prescription we proposed included removing PAAG, capsule, severe degenerated and harden tissue through multiple incisions (inframammary fold incision and additional incisions above the malposition area of PAAG which cannot be accessed through previous incisions). Incision and partial resection of the contracture tissue would then be performed to release the contracture if necessary. The defect left would be repaired with a free skin or flap grafting. The skin from the removed tissue would be used for grafting. Given the intensity of surgical trauma, we recommended delayed breast reconstruction with autologous tissue. This therapeutic maneuver would still be traumatic, costly and may lead to serious implications. For these reasons, she decided to forego treatment.
A 32-year-old male patient, presented with a Grade IIIA open fracture of the right distal femur, following a roadside accident suffered 22 hours back. Local examination revealed two (sutured) lacerated wounds on the distal one-third of the anterior and lateral aspects of the right thigh. There were no other injuries, and the distal neurovascular function was intact.\nAfter stabilization of the patient, he was taken up for surgery after 24 hours of admission (46 hours of injury). Through a lateral surgical approach (incorporating the existing wounds), the wounds were debrided, intercondylar fracture was stabilized with K wires and lag screws, and the distal femur fracture was stabilized with a locking plate. At the time of surgery, there was significant bone loss from the lateral and posterior parts of the distal femur, but bone grafting was not done due to the fear of infection in the contaminated wound which was being operated after a delay of 46 h. Wound was closed on a negative suction drain. The patient was put on gentamicin and cefoperazone/sulbactum. One week later, the wound was apparently healthy, so the patient underwent bone grafting at the fracture site. Intraoperatively, fluid and tissue from the fracture site were sent for culture, which came out to be sterile.\nOn the third day of the second surgery, the wound showed seropurulent discharge which on culture/sensitivity yielded pure growth of multidrug resistant K. pneumoniae. Since the organism was highly resistant, the patient was put on amikacin (1 g once daily), high-dose imipenem (1 g 8-hourly as infusion in normal saline over 2 h), and rifampicin (600 mg once daily). A repeat pus culture after 2 days again revealed the same organism. A decision for wound debridement and removal of bone graft was made and performed which resulted in healing of the wound. No further colonization with the same bacterium was detected by taking rectal swabs from that patient or from other patients hospitalized simultaneously in the same unit.\nIn the laboratory, K. pneumoniae isolate was found to be multidrug resistant by disk diffusion method as per the Clinical Laboratory Standards Institute (CLSI) 2011 guidelines. It was resistant to ceftazidime, cefotaxime, cefipime, gentamicin, amikacin, ciprofloxacin, aztreonam, amoxicillin/clavulanic acid, cefoperazone/sulbactam, piperacillin/tazobactam, ampicillin/sulbactam, cefipime/tazobactam, ertapenem, meropenem, doripenem, and imipenem. We screened the isolate for extended-spectrum β-lactamase (ESBL) production by disk potentiation test, but it was found to be negative. Evaluation of the isolate for ESBL using E-test strips containing ceftazidime at one end and ceftazidime–clavulanic acid at the other end, as well as Amp C β-lactamase by using E-test strips containing cefotetan at one end and cefotetan/cloxacillin at the other end was also negative. Minimum inhibitory concentration (MIC) of imipenem was ≥8 μg/ml by E-test, suggestive of carbapenemase production. Modified Hodge test on the isolate was negative, ruling out class A carbapenemases and pointing toward metallo-β-lactamases (MBLs). Phenotypic method with disk synergy test using imipenem and ethylenediaminetetraacetic acid (EDTA) and further genotypic detection confirmed the presence of blaNDM-1 gene [] in hospital-acquired K. pneumoniae isolate, conferring resistance to carbapenems including doripenem. The isolate remained susceptible only to tigecycline (MIC ≤1.5 μg/ml), colistin (MIC ≤1 μg/ml), and polymyxin B (MIC ≤1 μg/ml).\nDNA was extracted from the strain by heat boil method, and the DNA was subjected to single-target polymerase chain reaction (PCR). Two microliters of the extracted total DNA was subjected to PCR in a 50-μl reaction mixture. The PCR mixture for the detection of MBL genes contained 1 × PCR buffer [10 mM Tris-HCl (pH 8.3), 50 mM KCl], 1.5 mM MgCl2, 0.125 mM of each deoxynucleotide triphosphate, 0.1 μM of each primer, and 2 U of DNA polymerase. The primers used were F: 5′-GGGCAGTCGCTTCCAACGGT-3′ and R: 5′-GTAGTGCTCAGTGTCGGCAT-3′, which amplified an internal fragment of 475 bp for NDM-1 gene. Amplification was carried out under the following thermal cycling conditions: 10 min at 94°C; 36 cycles of amplification consisting of 30 s at 94°C, 40 s at 52°C, and 50 s at 72°C; and 5 min at 72°C for the final extension. Amplified products (475 bp) from the test strain and control strain were visualized under UV light on 3% agarose gel electrophoresis [].
A 78-year-old male, originally from China, with a past medical history of hypertension, diabetes, paroxysmal atrial fibrillation, and a stroke with residual left-sided deficit and waxing and waning mental status was brought to the hospital for weakness, urinary incontinence, confusion, and poor oral intake. On the day of his presentation, the patient was noted to appear weak on the left side more so than at baseline. The patient was brought to the emergency department as a stroke code; computed tomography (CT) scan of the head ruled out acute stroke. Vital signs were significant for a heart rate of 94 beats per minute and respiratory rate of 31 breaths per minute. The patient was admitted to the hospital for sepsis and workup for possible toxic, metabolic, or infectious insults leading to recrudescence.\nThe patient was started on empiric antibiotics, which were narrowed when blood cultures revealed gram-negative bacteremia speciating to Klebsiella pneumoniae, ampicillin-resistant, but sensitive to ceftriaxone. A CT scan of the abdomen and pelvis demonstrated the presence of a large cystic region with air-fluid level in the left lobe of the liver ( and ). Under the suspicion that this lesion was the source of the patient’s bacteremia, the patient underwent percutaneous drainage of the lesion by Interventional Radiology, which produced 80 cc of purulent fluid, also growing ampicillin-resistant, ceftriaxone-sensitive Klebsiella pneumoniae. While a stool ova and parasite examination on the patient was negative, further workup revealed that the patient was positive for Entamoeba histolytica antibody in the serum, detected via enzyme-linked immunosorbent assay and indicative of either current or prior infection. The patient had lived in the United States for several years, had no recent travel history and, to the knowledge of his family, had never been diagnosed or treated for E histolytica infection in the past; as such, he was started on metronidazole and paromomycin for extraluminal amoebic infection after completing the course of ceftriaxone to treat what appeared to have been a superimposed bacterial infection of a previously subclinical amoebic liver abscess (ALA).
A 44-year-old male presented to the emergency room with left shoulder pain of one day's duration. He also had fatigue, cough, arthralgias, and joint swelling. On physical examination, he was found to have decreased abduction of the left shoulder due to pain, and pain in the left trapezius with shoulder movement. The X-ray of the shoulder was unremarkable. All the labs were unremarkable including the Lyme disease panel. The patient was discharged on pain medication.\nThree months later, the patient presented to the ER with complaints of right-sided flank pain of one day's duration. The review of systems and physical exams were unremarkable. Labs were notable for small amounts of blood in urine analysis but were otherwise within normal limits. The CT scan of the back at that time showed no evidence of acute pathology. The patient was given IV fluids and pain control medication. His condition improved and he was discharged.\nThree days later, he returned to the ER with sharp back pain that he rated as a 10 out of 10 on the pain scale. He could not walk due to back pain. Vital signs were within normal limits. A review of systems was positive for left shoulder pain. On physical examination, he had a pruritic rash on the neck, and his leg strength was a 3/5 on neurological examination. He claimed to be in a monogamous relationship when questioned about his sexual history. All labs were within normal limits, and a CT scan of the head and lumbar spine revealed no abnormalities. MRI of the lumbar spine showed mild degenerative changes and ligamentum flavum hypertrophy, resulting in moderate neural foraminal stenosis (Figure ). He was admitted for foraminal stenosis and treated with steroids, and his condition subsequently improved. He was discharged three days later.\nThe patient went to visit his primary care doctor within a week. He was tired and could not feel his nose or ears. He had urinary incontinence and felt as if he was out of his body. His primary physician ordered a complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid screen, tick panel, sexually transmitted infection (STI) workup, erythrocyte sedimentation rate (ESR) test, and a vasculitis workup. STI workup was positive for rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) test. When the patient returned the next week, he experienced myalgia and was disoriented. A lumbar puncture was performed, which was positive for syphilis. He admitted to having a sexual encounter four months ago and to periodically having genital warts that usually resolved after two or three days. He was admitted to the hospital and treated with penicillin G potassium four million units intravenously every four hours for 14 days. He responded well to penicillin and was discharged home without any complications.
A 58-year-old female presented to the emergency department with intermittent, crampy right-sided abdominal pain, nausea, and vomiting, which began approximately 18 hours previously. Her past medical history was significant for hypertension and her surgical history included a thyroidectomy for treatment of thyroid cancer and a Caesarean section. A contrast enhanced CT abdomen and pelvis was obtained, demonstrating multiple fluid-filled, dilated small bowel loops in the right abdomen, which were predominantly anterolateral to the ascending colon and cecum (). In addition, two transition points were identified in the right lower quadrant, with one transition point at the distal ileum just proximal to the cecum and a second transition point in the proximal ileum. The two transition points were in close proximity to each other, indicative of closed loop obstruction. Decreased wall enhancement of the dilated small bowel loops was concerning for ischemia. Mucosal hyperenhancement of the ileum at the proximal transition point was felt to relate to ischemia or decompressed state (). Given the patient's symptoms and findings of closed loop obstruction on CT, the patient was taken to operating room. In the operating room, an internal hernia with closed loop obstruction was confirmed and resulted from herniation of small bowel through an adhesion of a transverse colon epiploic appendage to the ascending colon mesentery. The herniated small bowel was nonviable and a total of 60 cm of small bowel was resected (). Retrospectively, kinking of the ascending and transverse colon could be seen on the initial abdominal CT and was felt to correspond with the site of adhesion ().\nAfter resection, the patient's small bowel was left in discontinuity and an abdominal wound-vac was placed. The following day, the patient returned to the operating room, at which time the terminal ileum was also found to be nonviable. An ileocecectomy with enterocolonic anastomosis was performed.\nThe patient had a complicated postoperative course, but was ultimately discharged approximately two weeks after the initial surgery.
A 27-year-old male was admitted to hospital emergency due to 4 h of chest pain in 13 January 2016. In fact, he had suffered from fatigue after activity for more than 10 days and felt chest tightness and chest pain for 4 days before admission. The patient, a taekwondo trainee, had a healthy body, and his family history was unremarkable. Emergency aortic computed tomographic (CT) scan showed a thickened aortic wall, bilateral pleural effusion and pericardial effusion (Figs. a and b). Cardiac colour ultrasound suggested aortic hematoma or dissection (Fig. ). On the basis of the condition and the results of auxiliary examination, the formation of aortic dissection should be considered. The next day, after excluding surgical contraindications, the patient was performed an emergency operation. Cardiac surgeons underwent ascending aortic replacement and aortic arch replacement. They developed postoperative comprehensive treatment measures, including anti-infection, adjustment of cardiac function, nutritional nerve and symptomatic supportive treatment, and the patient recovered well and was discharged after 15 days. The cause of aortic dissection was unclear, although the surgeons extracted arterial tissues and pericardial tissues and sent them for pathological examination. In fact, postoperative pathology of the aortic wall tissue showed aortitis, such as visible necrosis, granulation tissue hyperplasia and a large number of acute and chronic inflammatory cell infiltration (Figs. b, c and d). However, the surgeons and the pathologist at the time did not consider the cause of aortitis or aortic dissection due to GPA because of a lack of understanding of GPA-induced aortitis or aortic dissection. This event is one of the starting points of our study. We want to attract the attention of clinicians. GPA is also a common cause of aortitis and even aortic dissection.\nOn the first day of 2017, the patient was re-examined for aortic CT because of a 6-day fever and right chest pain. He showed a good prognosis in terms of aortic dissection after a review of aortic CT, but we found significantly increasing lesions in his lung, such as flake density increased shadow, less clear boundary, visible cavity and bronchial meteorology (Fig. c). The patient had no renal insufficiency and sinusitis but had eye damage with scleritis. The next day, the patient was readmitted to our hospital. At first, we considered pulmonary infection because of the combination of fever, haemogram, pulmonary shadow and cavitary lesions. Hence, we administered moxifloxacin. After 12 days, we reviewed chest CT again and found that the lung lesions became significantly heavier than before (Fig. d). Moreover, the patient still had intermittent fever, and the infection treatment was ineffective. At the same time, the patient developed conjunctivitis in the left eye and pain in the finger joints. Thus, we started to suspect pulmonary infection. We checked connective tissue disease-related indicators, such as ANCA, anti-nuclear antibody and immune indicators. The proteinase 3 (PR3)-ANCA (c-ANCA) level was 180 IU/mL, and the MPO-ANCA (p-ANCA) level was 10 IU/mL. Rheumatoid factor and anti-O experiments were positive, and anti-nuclear antibody spectrum was negative. We then performed a bronchoscopy, including brush biopsy, bronchoalveolar lavage and transbronchial lung biopsy. The pathological results suggested inflammatory cell infiltration, cellulose exudation and necrosis in clamped lung tissues (Fig. a). However, these pathological changes may be insufficient to diagnose GPA. We therefore carefully re-examined the pathological findings of the patient’s aorta and pericardium one year ago. Surgical biopsies obtained from the aorta and pericardium tissue showed that the epithelioid cells and multinucleated giant cells formed a granuloma (Fig. b), small vasculitis (Fig. c and Additional file : Figure S1 and Additional file : Figure S2) existed in the aorta and cellulose exudation and inflammatory granulation tissue hyperplasia were present in the pericardium (Fig. d).Combining with the two pathological results, clinical manifestations and laboratory tests, we invited a radiologist and a pathologist to perform a multidisciplinary discussion in the initial diagnostic assessment of the patient with suspected GPA. Finally, the diagnosis of GPA was established. Then, immunosuppressive therapy with i.v. steroids (methylprednisolone 40 mg twice daily) and cyclophosphamide 125 mg·day− 1 was initiated. The patient is currently followed up with the above treatment programs. We also adjusted the treatment program according to the patient’s disease progression. At present, the patient recovers well and is in stable condition.
A 35-year-old male patient presented to us for left-sided chest pain for 1 month. There was no associated cough or fever. His past history revealed surgical removal of a left parieto-occipital brain mass with histological diagnosis of grade II astrocytoma at a private hospital, 3 months back. At that time there were no respiratory symptoms.\nOn examination, patient was healthy male with no abnormality on physical examination. Chest examination revealed a dull percussion note and decreased breath sounds at left upper lung fields. X-ray chest revealed a mass lesion at left upper zone with shift of mediastinum to the right side []. Routine investigations of blood and urine and other biochemical tests were normal. Computed tomography (CT) scan chest revealed a lobulated, soft tissue mass at left upper lobe, measuring 12.7 × 11.3 × 17 cm and extending toward the mediastinum. The density of mass was heterogeneous with clear, dark, and gray areas representing necrosis and hemorrhage in the tumor []. The radiological features were highly suggestive of a malignant neoplastic lesion. A percutaneous transthoracic FNA was done from left suprascapular region. The smears were highly cellular with irregular branching tissue fragments containing moderate pleomorphic, bipolar spindle cells showing small to medium-sized ovoid to spindled nuclei having evenly distributed bland chromatin, inconspicuous nucleoli, and occasional mitotic figure. The cytoplasm was scanty and delicate. Some bare nuclei were also seen []. The cytological diagnosis of smears was reported as malignant spindle cell tumor with strong possibility of monophasic synovial sarcoma or fibrosarcoma lung. The tissue blocks of brain mass reported as astrocytoma from the private hospital were asked for and reviewed by the authors. Review of the histopathologic sections of brain tissue mass revealed histological appearance suggestive of monophasic synovial sarcoma []. To further confirm the diagnosis, tissue blocks and FNA smears were subjected to immune histochemistry (IHC) that showed positive reaction for cytokeratin, vimentin, bcl-2 protein, calponin, and epithelial membrane antigen (EMA). The S-100 protein, glial fibrillary acidic protein (GFAP), synaptophysin, and chromogranin-A markers were negative on IHC. A thorough search was done to rule out any primary site. A final diagnosis of primary monophasic synovial sarcoma lung with brain metastasis was made as there was no evidence of any tumor in the vicinity of bones, joints, or soft tissue. Patient was referred to radiation oncology department where he received concomitant chemotherapy with temozolamide and radiotherapy to the skull. Patient survived 6 months after initial diagnosis with pleural effusion, ascites, and anasarca as a terminal event.
A healthy 36-year-old man sustained a close-range, low-velocity gunshot wound during an assault. The bullet length was 1.5 cm []. The patient was initially examined by the trauma team in the emergency room for a gunshot wound to the lower abdomen. The patient was hemodynamically unstable. The entrance wound was located in the left lower quadrant area but no identifiable exit wound was seen. Initial radiologic studies showed that the bullet was embedded in the acetabulum and possibly also intra-articularly []. The patient had a tense abdomen and there was a frank blood from the Foly catheter. He was immediately taken to the operating room and subsequently underwent a trauma laparotomy with small bowel repair, large bowel resection, primary anastomosis, and bladder repair with insertion of a suprapubic catheter. The major bullet fragment was not visible during pelvic exploration. Post-operatively, intravenous antibiotics were administered. The Department of Orthopedics was consulted for a retained intra-articular bullet fragment shown on a computed tomography (CT) scan [], which was done because of ongoing low hemoglobin despite frequent blood transfusion. Physical examination revealed an intact soft tissue envelope around the hip and pelvis with an entrance wound as noted in the left suprapubic area. Neurologic status was intact. The patient did have some moderate hip pain with a range of motion but was able to perform a straight leg raise with the involved extremity, with only slight discomfort. Laboratory values including a white blood count were within normal limits, the patient was afebrile, and there were no signs of a septic joint. Patient was taken to the operating room for pelvic exploration versus hip arthroscopy. The decision was made to proceed with hip arthroscopy to remove intra-articular debris, assess the chondral surface to avoid any further damage to the femoral head by the retained fragment, and prevent the late sequelae of lead intoxication. Pelvic CT scan showed a major bullet fragment in the superomedial portion of the acetabulum, projecting into the joint. The femoral head was damaged significantly.\nHip arthroscopy was performed using the supine position with the involved extremity in traction on a fracture table. A spinal needle was used for localization, following which an anterolateral portal was established first using the Seldinger technique with fluoroscopic guidance []. A hemarthrosis was evacuated and an anterior portal was established using the same technique. A large capsulotomy was performed with the shaverand ablation devices to facilitate bullet removal. The bullet was found embedded in the medial acetabular wall []. It was dislodged and then removed from the inferior acetabulum with an angled pituitary grasper []. The surface of the femoral head was damaged by the projectile []. Intraoperative fluoroscopy verified removal of the entire fragment []. Post-operative plain-film radiographs showed very small bony fragments beside the entry point []. The joint was irrigated utilizing 6 liters of normal saline. We used low-pressure flow (20 mm Hg) and a series of suctioning to minimize the risk of abdominal compartment syndrome and its consequences.[] The portals were closed in the routine fashion. The patient's abdomen remained soft following the procedure. No complications were encountered. A first-generation cephalosporin was administered post-operatively, and physical therapy was commenced on the next few days, with weight bearing for tolerance and gait training with crutches. Post-operative computed tomography scan showed very small bony fragments beside the entry point [].
Patient: a 55-year-old Japanese female. None of the factors contributing to lateral compartment knee disease, such as obesity, complications, or psychiatric disorders, were present in the patient. During hyaluronic acid (HA) treatment, although we prescribed strength training to the patient, she did not perform it frequently enough because of severe pain. As the knee pain was caused by tripping while playing tennis, the possibility of trauma cannot be ruled out. In 2013, due to pain in both knees, she visited our hospital and was diagnosed with OA of the knee. In December 2017, while playing tennis, the right knee developed a knee collapse. She was examined at the hospital, and an MRI of the right knee was performed. Horizontal dissection of the lateral meniscus and cartilage defect on the lateral condyle of the femur were observed. Since 2018, injections of hyaluronic acid have been administered every 2 weeks, but joint edema and pain recurrence have been remitted. The patient had already undergone HA treatment and received multiple steroid joint injections; however, these interventions were not very effective. Moreover, the patient was unwilling to undergo these treatments. The patient was aware that our hospital would start providing regenerative medicine treatments and had been waiting for a year before the start of the treatment. During that period, the patient received HA treatment, which proved ineffective. Therefore, the patient requested ASC treatment in April 2018. In April 2018, MRI of the right knee was performed. A cartilage defect was found in the external condyle of the femur, and the patient desired ASC transplantation. The range of motion of the right knee is 0–145. Anteroposterior (AP) and lateral radiograph of the right knee are shown in Fig. . On 28 April 2018, 20 mL ASCs were collected from the abdomen. On 11 June 2018, the first ASC transplantation was performed on the right knee. On 2 July 2018, although the effect was experienced after 1 week
Patient 1, a 48 year old female, who had a history of progressive heart failure, dyspnoea at rest and cyanosis for three weeks prior to hospitalization. The patient had no complaints of fever above 38 C, night sweating or loss of more than 10 % of body weight over a period of six or less (B symptoms). On the day of hospitalization a transthoracic echocardiography (TTE) was performed. An inhomogeneous tumour was found in both atria. It was almost closing the orifice of the tricuspid valve (the diameter of the tricuspid valve orifice was 2.38 cm and the diameter of the part of the tumour closing the orifice was 2.25 cm) and penetrating the left ventricle via the interventricular septum. Complete blood count (CBC) and coagulation profile test (CPT) were within normal limits. The patient was immunocompetent and human immunodeficiency virus (HIV) tests were negative. Due to a rapid and severe heart failure an open chest operation was performed, during which a biopsy of the tumour was taken. Fast intra-operative analysis of the specimen revealed that the tumour was malignant. Because the tumour was inoperable and the patient’s hemodynamics was unstable, a decision was made to perform a Fontan procedure as a palliative method in order to stabilize the patient’s condition and to provide time for chemotherapy. The superior vena cava (SVC) was anastomosed to the right pulmonary artery (RPA) (Fig. ). This way venous blood flow was redirected to the lungs and obstructed right heart was bypassed. After the surgery, the patient’s condition improved. She was extubated on the second day after the surgery. Breathing was spontaneous and arterial blood oxygen saturation (SaO2) was 92 %. A detailed histological exam of the tumour revealed that it was diffuse large B cell lymphoma. There were no evidence of extra-cardiac lymphoma present, thus the final diagnosis was primary cardiac lymphoma. When the patient recovered from the surgery, she decided to continue her chemotherapy treatment at a foreign oncology clinic. To the best of our knowledge, the patient went into remission after chemotherapy.
We present the case of a 30-year-old Nigerian male who was brought to the Surgical Emergency Department of the Lagos State University Teaching Hospital Ikeja 22 hours after he had inserted a constricting ring over his penis. He had developed a painful penile shaft swelling distal to the ring with suprapubic pain and swelling secondary to acute urinary retention. There was associated urethral bleeding.\nThere had been failed attempts at removing the ring by self and the resulting severe pain drew the attention of his relatives who brought him to the emergency room.\nHe had a history of a psychiatric illness and the patient claimed he was under a spell and had heard a voice that instructed him to insert a ring over his penis. He denied using the ring to sustain erection and claimed it was his first time of inserting a ring over his penis.\nThe patient had a history of deterioration in personal and general performance with underachievement dating back to 7 years prior to presentation when he voluntarily dropped out of the university and had done nothing tangible thereafter.\nTwo weeks prior to presentation, the patient's relatives had noticed some unusual behavior in him characterized by talking to self and rubbing salt over his body and the patient claimed he was being chased by unseen people.\nHe had a history of alcohol, cigarette, and cannabis abuse for about 15 years.\nOn examination, he was in acute urinary retention with a tender suprapubic distention up to the level of the umbilicus.\nThere was a thick constricting ring at the root of his penis. There was a markedly swollen oedematous penis distal to the ring with marked reduction in sensation over the penis and glans ().\nWe made a diagnosis of Constrictive Penile Injury (Bhat Grade III) with acute urinary retention [].\nHe had a suprapubic cystostomy done to relieve the acute urinary retention as a urethral catheterization was impossible.\nAttempts were made to remove the constricting ring by the use of aspiration, application of cold compress, and lubrication initially and later by the use of the string method.\nFollowing failed attempts at removing the device with these different manipulations and unsuccessful attempt at cutting with the manual saws available in the hospital coupled with the fact that the patient appeared to have imminent penile gangrene, a decision was made to call the fire service for a power driven saw.\nThe ring was successfully removed by cutting it at two different points () with a power driven arc saw () under conscious sedation at the emergency room.\nThermal injury was prevented by intermittent cooling with ice packs and injury to underlying tissue was prevented by insinuating a pair of artery forceps between the penis and the ring ().\nDressing of the resulting penile skin ulceration was done and the plastic surgery team was invited for possible additional wound care.\nThe patient was also reviewed by the psychiatric team who made a diagnosis of schizophrenia and commenced the patient on haloperidol. He was to be followed up on an outpatient basis in the psychiatry clinic.\nThe patient reported normal nocturnal erections while on admission. Further evaluation of the suspected urethral injury with urethrogram and a urethroscopy was planned but this was declined by the patient who opted to retain his suprapubic catheter.\nThe patient also declined any additional wound care by the plastic surgery team and the wound was healing satisfactorily by secondary intention as at 2 weeks after the initial presentation ().\nHe subsequently defaulted from care.
A 28-year-old man presented with a growing soft mass on the vertex of his head; it had developed 5 months earlier. Sixteen months prior to this, the patient had been involved in an incident in which he had received a blow to the head. Initially, he had a small subgaleal hematoma but it disappeared by the following day. Patient did not visit hospital for the head trauma; thus, head computed tomography (CT) and X-rays were not performed at that time.\nTwo years ago, the patient was diagnosed with bipolar disorder, and it was because of this that he underwent a physical examination and EEG for evaluation of his psychological state one month after the incident. At this time, no mass was detected on his scalp. Also, he did not feel the mass on the scalp. It was not until 8 months later that a mass developed, which continued to grow. The patient experienced no associated symptoms, and the mass was not tender to touch. A plain X-ray revealed a round 5×5 cm area of lucency in the posterior parietal bone with adjacent skull erosion. Upon enhanced CT examination of the head, a bony defect involving both the inner and outer table of the cranium was observed close to the superior sagittal sinus. A well-defined mass, 5 cm in diameter, was nested within the defect (). There were no enhancing lesions inside the cyst, and the rest of the brain parenchyma was free from notable anomalies. Magnetic resonance imaging (MRI) of the lesion was hypointense on T1-weighted images and hyperintense on T2-weighted images, indicating that a cystic lesion was propagating through the defect and slightly compressing the adjacent brain.\nFollowing this, the patient underwent surgery. A skin flap was created close to the lesion by making an incision down to the galea. The underlying lesion was pulsatile. The galeal layer was then dissected from the cyst, which exposed the cystic membranes. These membranes protruded through the bone defect and contained a clear fluid. The dura around the bone defect was thin and fragile.\nUsually, dura is sutured in a watertight manner with artificial dura, such as lyophilic dura. However, due to the close proximity of the defect to the sagittal sinus, we chose instead to place fibrinogen-based collagen fleece (TachoComb®) over the dural defect in order to reduce the risk of injuring or perforating the sinus. Six pieces of fibrinogen-based collagen fleece, cut to a size of 1×3 cm, were thus placed over the dural defect in a partially overlapping manner. The gluing surface of the fibrinogen-based collagen fleece was attached to the dural defect, exceeding the margins by about 0.5 cm. A wet patty was then applied over the defect and gently compressed. After the patty was removed, any extra seepage of blood was prevented by the application of an additional layer of fibrinogen-based collagen fleece on top of the existing layer (). The outer table of the skull was reconstructed.\nThe day after surgery, the patient remained asymptomatic and displayed good cosmetic results. Histologic findings revealed that the cyst was lined by meningothelial cells resting on a layer of supporting fibrous tissue. The walls of the cyst were infiltrated with mild chronic inflammatory cells and displayed vascular congestion. The cyst surface was focally lined with flattened epithelial cells, and the underlying brain tissue had become gliotic. The presence of chronic inflammatory cells and hemosiderin-containing macrophages suggested traumatic etiology (). Thirteen months later, a follow up brain CT scan of the patient revealed no recurrent cystic mass ().
We present the case of a 27 year old lady who was seen in the infertility clinic with a history of secondary infertility of a one-year duration. Her BMI was 32. She had two children born by vaginal delivery, and last childbirth was five years ago. Following that she was investigated for heavy periods and stress incontinence and underwent hysteroscopy, Mirena insertion, TVT secure, and posterior repair on the same day. During the first coil check with her general practitioner (GP) 6 weeks after the insertion, the coil strings were not seen and therefore an ultrasound scan was arranged. The Mirena coil was not seen on the scan and was thought to be expelled. No further investigation was arranged.\nApproximately a year and a half following that she was seen in the infertility clinic. She gave a history of few months of implanon use for contraception before discontinuing and trying for conception. She had irregular cycles varying from 4- to 8-week intervals and no history of intermenstrual or postcoital bleeding. Her cervical smears were normal and had a prior episode of CIN3 nine years ago treated with LLETZ. There was a history of chlamydia and herpes infections treated in the past. She had a medical problem of ectopic heart beats due to inherited cardiac condition of long QT syndrome for which she had an implantable cardioverter-defibrillator (ICD) inserted five years ago. This was diagnosed following investigations of sudden cardiac death of her brother. She was a nonsmoker and had 18 units of alcohol per week. Her current partner was 34-years-old and was fit and well with no significant past history. He had fathered a child in his previous relationship.\nFindings on clinical examination of the couple were normal. The initial investigations done revealed a normal follicular phase, normal serum prolactin, and luteal phase serum progesterone of 28.9 indicating anovulation or borderline ovulation. The semen analysis was normal. A hysterosalpingogram was arranged to check for the tubal patency and it revealed both tubes to be patent and finding of misplaced coil outside the uterus in the abdominal cavity.\nThe couple were reviewed with the investigation results and the lady was counselled regarding a laparoscopy and retrieval of the extrauterine Mirena coil which she agreed to. She was advised to switch off the tachycardia component of the ICD prior to the operative procedure. During laparoscopy the coil was seen in the pouch of Douglas and no adhesions were noted. The uterus was of normal size and there was evidence of old fundal perforation. Both tubes and ovaries were normal in appearance.\nA followup was arranged in the infertility clinic three months later. Prior to that she confirmed having a positive pregnancy one month after the Mirena coil removal.\nShe was referred to the high-risk pregnancy clinic for followup in view of having a cardiac defibrillator and previous history of TVT. Her pregnancy is progressing uneventfully and she is currently 25 weeks pregnant.
A 31-year-old man with no previous medical history was transported to the Emergency Department (ED) by ambulance on a spine board and with a cervical collar in place after a car accident. The patient was the restrained vehicle driver and the Emergency Medicine Services found him at the scene soon after a collision with a bus. His initial vital signs were notable for a blood pressure of 122/72 mm Hg, a heart rate of 122 beats/ min and a respiratory rate of 22 breaths/ min.\nOn arrival to the ED, the patient had a blood pressure of 115/65 mm Hg and a pulse of 128 beats/ min. Airway was patent with an oxygen saturation of 99 % through an oxygen mask. On primary survey, equal breath sounds were auscultated with no signs of associate underlying lung injury. Heart sounds were tachycardic but otherwise normal along with intact distal pulses in all extremities. Fluid resuscitation with normal saline was initiated in the field and continued through two large bore intravenous lines at both antecubital fossae. The patient’s GCS was calculated to be 15/15. Full body exposure revealed ‘seatbelt’ sign in the right lower quadrant of the abdomen and no other signs of traumatic injuries.\nOn secondary survey, abrasions were noted on both upper extremities and there was abdominal discomfort with diffuse tenderness, guarding over the lower part of the abdomen with no signs of distension. The focused assessment with sonography for trauma examination (FAST) revealed a mixed-echogenicity subhepatic mass, suspicious for intraperitoneal hematoma. Chest, cervical spine and pelvic radiographs showed no abnormalities. Given his relative hemodynamic stability head to pelvis CT scanning was performed, which showed a hematoma of the mesocolon of the ascending colon with active extravasation of intravenous contrast material, originating from a branch of the right colic artery. A pseudoaneurysm of this arterial branch was also noted along with displacement of the ascending colon, resulted from the hematoma of the mesocolon (Figs. and ).\nDiagnostic laparoscopy was a consideration as a management option but due to the deterioration of patient’s condition with increasing abdominal pain and overt peritoneal signs along with hemodynamic instability, the surgeon’s choice was to take the patient to the operating room for exploratory laparotomy with the fear that the induction of pneumoperitoneum would compromise venous flow return and could be easily fatal in this particular case. A median laparotomy was performed and an estimated 300 cc hemoperitoneum was evacuated. Intraoperative findings included a subserosal hematoma along the cecum and the adjacent segment of the ascending colon with areas of totally disrupted serosal wall (Fig. ). There was also a v-shaped hematoma of mesocolon adjacent to injured bowel, expanding to the origin of the mesenteric vessels (Fig. ). Intraoperative findings revealed no other traumatic injuries in abdominal structures. A standard right hemicolectomy along with primary ileotransverse colonic anastomosis was performed.\nThe patient was taken to the recovery room post-surgery in a stable condition and admitted to surgical intensive care unit. The postoperative course was uneventful and the patient was discharged on post-operative day seven without any problems.
A 60-year-old woman came with the complaints of easy fatigability, persistent dull aching headache for the past 3 months with intermittent episodes of aggravation. Headache was predominantly localized on the right side and throbbing in nature. She also had a nodular growth over the right forehead measuring about 2.5 cm × 2.5 cm for 3 months. It began as a small nodule of pea size and progressed to about 1 cm × 1 cm. Due to pain over the swelling, she went to a local practitioner and got it excised. However, the swelling recurred and grew to its present size over a period of 1½ months. There was no alteration in appetite, bowel, and bladder habits or weight loss. She had a history of total abdominal hysterectomy done for multiple uterine fibroids, 6 months back.\nLocal examination of forehead swelling showed a nodular surface with an overlying scar mark of previous excision []. The swelling was fixed, nontender, and nonpulsatile on palpation. The patient also had a firm, fixed swelling over right chest wall measuring about 4 cm × 4 cm []. There was no other palpable organomegaly. Her serum chemistry and blood investigations were within normal limits. Contrast-enhanced computed tomography (CECT) of head revealed a large heterogeneously enhancing mass of approximately 5 cm × 4 cm in the right frontal region. The lesion caused destruction of both outer and inner tables of frontal bone along with inward compression of the right frontal lobe []. CECT chest and abdomen also revealed a heterogeneously enhancing mass lesion measuring 5.7 cm × 4.1 cm × 3.5 cm in superior and posterobasal segment of the right lower lobe with evidence of infiltration into right branch of inferior pulmonary vein. Multiple nodular opacities with few showing spiculations were seen in bilateral upper lobes []. Also seen was a pleura-based soft tissue dense enhancing mass involving the right posterolateral chest wall with the destruction of right 10th rib []. There was evidence of contiguous infiltration of the mass into overlying subcutaneous fat and right posterolateral chest wall.\nMultiple FNAs were performed from forehead and lateral chest wall nodular masses. Smears prepared from both sites showed similar morphology. Pleomorphic tumor cells were seen predominantly in cohesive overlapping clusters with hyperchromatic oval to bizarre nuclei. At places, the cells were seen embedded in a pink matrix material. Features were those of a poorly differentiated malignant tumor. Immunocytochemistry could not be performed, as the patient did not consent for a repeat FNA. The patient was asked to retrieve paraffin blocks from previously resected forehead nodule. Reviewed histomorphology and serial sectioning revealed elongated fascicles of a cellular spindle tumor with cells displaying moderate anisokaryosis along with occasional bizarre nuclear form. Mitosis was evident along with foci of necrosis. Lymphovascular emboli were not identified [–]. Overlying skin was free of tumor. A panel of immunohistochemical stains was put up for further characterization. Tumor cells were strongly positive for vimentin, muscle specific antigen (MSA), and smooth muscle actin (SMA) along with distinct perinuclear dot positivity for pan cytokeratin (pan-CK) [–]. Cells were negative for desmin, S-100, and CD34. A final diagnosis of metastatic leiomyosarcoma was given. In an attempt to locate the primary and considering patients sequential history, her previous hysterectomy specimen was retrieved and extensively regrossed. Serial sections revealed leiomyoma with two 10 mm and 7 mm foci showing moderate nuclear atypia, stippled necrosis, and evident mitosis; consistent with leiomyosarcoma. Hence, a final impression of ULMS with metastasis to chest wall and forehead was made. The patient was started on a chemotherapeutic regimen comprising of three cycles of gemcitabine/docetaxel, followed by intensity modulated radiation therapy to abdomen. The patient became symptomatically better for a few weeks. However, a 6-month follow-up computed tomography scan chest, done posttherapy was suggestive of approximately 20% increase in size of mass in lower lobe and right chest wall; indicating progressive disease. The patient is now further planned for intensified chemotherapy regimen.
A 22-year-old male with a history of ongoing IV heroin abuse presented to the hospital with a cough productive of reddish sputum and shortness of breath of 4 days duration. He denied fever, chills or other systemic symptoms. Past medical history was significant for a recent episode of left arm cellulitis around 2 months earlier which had resolved after treatment with amoxicillin-clavulanate. He had been seen several times in the outpatient and inpatient setting in the past for substance abuse where attempts at detoxification and rehabilitation had been unsuccessful.\nThe patient was in respiratory distress on presentation, and his vital signs revealed oxygen saturation of 85%, blood pressure of 170/95 mmHg, pulse rate of 99/min and respiratory rate of 25/min. Physical exam showed track marks in the left antecubital fossa and bilateral coarse rhonchi in all lung fields. The patient was emergently intubated and admitted to the intensive care unit for management of respiratory failure.\nA chest X-ray () was obtained and showed the presence of multifocal rounded airspace opacities within both lungs. Subsequently, a CT scan of the chest (, ) was obtained which demonstrated bilateral pulmonary emboli along with bilateral conglomerate pulmonary nodules in both lower lungs.\nBased on patient’s history of IV drug abuse, recent episode of cellulitis, concomitant lower back pain and consistent imaging findings, the diagnosis of right-sided infective endocarditis with septic pulmonary embolism was initially considered and patient was empirically started on IV antibiotics after drawing blood cultures. However, a transthoracic echocardiogram obtained the next day did not reveal any vegetations and the patient continued to remain afebrile with all blood cultures coming back negative. This prompted a reconsideration of the diagnosis. All radiographic images were reviewed again with radiology and were notable for the lack of necrosis in the pulmonary nodules. A follow-up abdominal CT also revealed the presence of retroperitoneal lymphadenopathy indicating a possible neoplastic process.\nA thorough physical exam was performed again which revealed the presence of a small left testicular mass. Ultrasound of the testes was obtained which showed two complex left testicular masses containing cystic and solid components as well as microcalcifications. His serum alpha fetoprotein, lactate dehydrogenase and beta-human chorionic gonadotropin were all found to be elevated.\nThe patient was diagnosed with metastatic non-seminomatous germ cell tumor of the testis. Because of the large tumor burden, he was started on chemotherapy with cisplatin, etoposide and iphosphamide, and orchiectomy was deferred for a later stage when he was more stable. He was extubated after receiving his first cycle of chemotherapy, and underwent left orchiectomy and retroperitoneal lymph node dissection soon after, with biopsy confirming the diagnosis of germ cell tumor with residual viable teratoma. He continues to receive medical care for malignancy as well as for substance use disorder as an outpatient.
A 64-year-old woman was referred to our Hospital for further evaluation of a symptomatic pancreatic mass, which was revealed on B-mode sonography. Two months before referral, she experienced persisting epigastric pain following a heavy meal. An upper gastrointestinal endoscopy revealed early gastritis and a positive CLO test for Helicobacter pylori. The patient received treatment for H. pylori eradication, improving her overall condition but failing to completely control the epigastric pain. Abdominal sonography was performed—for possible cholelithiasis—revealing a mass in the body-tail of the pancreas and thus the patient was referred to our institution for further investigation and management. She was diagnosed 6 years ago with multiple sclerosis complicated by cardiomyopathy for which she was under treatment. She had no history of trauma, pancreatitis, or other congenital abnormalities, and the only surgery she had undergone was right inguinal hernia repair. On physical examination, intense blepharoptosis was noted with generalized muscle weakness. Mild epigastric tenderness but with no definite mass was as well noted. Laboratory data were grossly normal apart from slightly elevated liver aminotransferases and γ-glutamyl transpeptidase, which were compatible with the sonographic finding of fatty liver infiltration. Serum amylase levels were within normal limits, as were serum Ca19-9 and CEA levels. The patient was tested negative for hepatitis B and C virus. She underwent abdominal CT and MRI scans, which in conjunction with the angiography that followed and revealed vascular distribution from the splenic artery, led to the diagnosis of pancreatic arteriovenous malformation (PAVM) (Figures , ). On the CT images, the spleen was not oversized, while some varicose vessels with the more prominent one arising from the right gastroepiploic vein were noticed. At the same time, clinically there were no signs of portal hypertension. After explaining the severity and risks of a possible operative management, the patient refused any surgical intervention. Transcatheter arterial embolization was indicated and performed with acceptable results. Our objective for treatment, as for most of arteriovenous malformations, was to occlude as many of the shunts in the AVM as possible, so as to reduce the risk of portal hypertension, haemorrhage, and of course to alleviate pain, which was the initial clinical indication for intervention. A few hours after the intervention, the patient complained of a mild left upper quadrant pain which completely resolved within the next 24 hours. A slight increase in serum amylase (198 U/L) was noticed the next morning, which normalized in the next 2 days. There was no notable elevation of liver enzymes compared to the preinterventional levels, and the white cell count remained normal throughout the patient's admission. A day after the embolization, a repeat CT scan was performed. Embolic material was seen within the PAVM. A small number of embolic particles measuring only a few millimeters in size were seen scattered within the liver parenchyma and the spleen with concomitant small peripheral infarcts (). The patient was closely observed and monitored after the embolization and only required mild pain relief. The patient after two years of followup remains asymptomatic, with only a few episodes of mild epigastric pain which may or may not be attributed to the PAVM. The small splenic infarcts have resolved without causing any complications such as persistent pain or abscess, which is seldom observed especially after small-sized infarcts as in our case. No signs of complications such as gastrointestinal bleeding or portal hypertension have been noticed.
A 61-year-old woman, gravida 3 para 3, last menstruation at 54 years of age, reported to her gynecologist complaining about irregular post-menopausal hemorrhaging and a mass emerging from the external cervical opening she palpated. She presented no other symptoms or complaints, including no pain whatsoever. Her gynecologist referred her to the Obstetrics and Gynecology Clinics emergency room. On admittance, physical examination revealed no irregularities apart from a solid palpable mass in the cervix. A pre-operative imaging was performed, in this case an ultrasound examination, using a transvaginal probe, that confirmed the presence of a 5.5 cm polyp that expanded the cervix. Moreover, the patient suffered from stage 2 arterial hypertension and class 3 obesity (BMI = 40), and had undergone a single surgery in the past, an open appendectomy. Her mother suffered from a neoplasm (most likely pancreatic cancer); there were no other diseases in the family history.\nThe patient underwent a surgical procedure of excising the polyp at its peduncle using a LEEP loop electrode. It could not be removed in one piece—the polyp fragmented into several pieces during extraction. Then, a curettage of the cervix and an unsuccessful attempt of a uterine cavity curettage was performed. Obtained tissues were then sent to the pathology department for a histopathological examination. The findings were ready in six weeks after the procedure and revealed the presence of rhabdomyosarcoma embryonale (type botryoides) in the excised polyp. Due to the fact that the polyp was fragmented during extraction, a precise margin status or the depth of invasion could not be properly determined. Histopathological images are presented in .\nThe immunohistochemistry results are shown in . They correlate with results typically seen in ERMS.\nThe patient was then referred to our gynecological ward that specializes in oncology. In our outpatient clinic, a chest CT and pelvis MRI of the pelvis and the abdomen were performed and the presence of metastasis was excluded. Her treatment was then thoroughly discussed by an oncological council and further therapy was planned.\nThree months after the initial hospitalization, the patient was admitted to the onco-logical gynecological ward. On admission she presented no irregularities in gynecological examination. A transvaginal ultrasonography of the uterus and pelvis was performed and a myoma, ca. 5 cm in diameter was found in the uterus wall. No other lesions were identified. A preoperative MRI of the abdomen and pelvis allowed identification of another 4 myomas in the uterus, with sizes from 7 to 54 mm, as shown in .\nAdditionally, in the posterior wall of the cervix an irregular area (14 mm × 25 mm × 9 mm) was found, which was probably a malignant lesion. A single lymphatic node in the right inguinal area, with a diameter of 10 mm, was also identified. Remembering her symptoms and a history of a neoplasm in her family, the patient demonstrated a high level of anxiety towards her neoplasm. She expressed a wish to implement a radical treatment to ensure a disease-free result and this was also taken under consideration while choosing the therapeutic path.\nWe performed a Wertheim–Meigs operation—an extended uterus excision with bilateral pelvic lymphatic nodes removal. Additionally, as preserving fertility in this patient was not a priority, we excised the ovaries, the fallopian tubes and the surrounding tissue to ensure radicality of the procedure. All of the removed tissues were then forwarded to the pathology department. No adjuvant chemotherapy or radiotherapy was administered. The patient was discharged from the hospital in good general condition.\nThe histopathological results showed no signs of the rhabdomyosarcoma in the excised tissues; this may indicate that all malignant lesions were placed in the polyp and were successfully removed during the initial procedure. Moreover, none of the excised lymphatic nodes showed traces of neoplasm cells.\nAfter the surgery, the patient was regularly monitored in the outpatient clinic in the first year once every 3 months and afterwards once every 6 months. Three months after the surgery, a cytological examination was performed and no irregularities were found. The patient showed no symptoms and reported no complaints. One year after the surgery a CT scan of the chest and MRI of the pelvis and abdomen were performed—with no signs of neoplasm whatsoever. A postoperative MRI of the pelvis is shown in .\nThe patient still remains under our care, with biannual control visits, the same as every patient treated for a gynecological malignancy in our clinic. At her last control visit, two years after the initial surgery, she presented no symptoms and no complaints whatsoever. An ultrasound was performed in which the postoperative organ site was filled with intestinal loops; no free fluid or pathological lesions were observed. The most recent cytological examination did not show any signs of neoplastic cells. Up to this day, no signs of recurrence or symptoms connected with the ERMS were identified.\nThe patient’s mental and psychological status, as well as her life satisfaction after recovering from the disease was evaluated, using Beck’s Depression Inventory II, Satisfaction with Life Scale, General Self-Efficacy Scale and Coping Inventory for Stressful Situations Scale. Detailed results are presented in .\nThe patient shows no signs of depression or dissatisfaction regarding her current life. When encountering a problem, she presents a task-oriented coping mechanism—first she analyzes a given situation, and then deals with it, following a plan she made. Moreover, she is sure that if a problematic situation would appear, she would be capable of managing it. All this shows that our patient, despite expressing a high level of anxiety during the diagnostic and therapeutic process, is now in great mental shape and is satisfied with her life.
A 35-year-old man presented initially with progressive weight loss and anemia. CT showed mediastinal lymphadenopathy complicated with superior vena cava (SVC) compression and diffuse liver infiltration. Small bibasal pleural effusion, pericardial effusion, and venous collaterals were also present secondary to the vena cava compression. He has medical history of asthma, chronic gastric ulcers, and cervical spondylosis. The working diagnosis was lymphoma with secondary organ infiltration, thus requiring a confirmatory tissue biopsy.\nHe was unable to tolerate bronchoscopy under sedation, as he was not fit for general anesthesia. He was then referred to the radiology department for percutaneous CT-guided biopsy of the mediastinal mass. There were two masses that were amenable for biopsy; the mass that paralleled the arch of aorta and the mass behind the compressed SVC. We chose the latter using a posterior approach. There were two attempts using a semiautomated 18-G biopsy needle yielding a good core from the biopsy. Post biopsy, the patient was asymptomatic.\nThree hours post biopsy, the patient became tachypneic with deteriorating vital signs and an urgent CT was carried out. A multi-phase CT with arterial, portovenous, and delayed phases was done and showed contrast extravasation at the posterior segment of the right upper lobe and a large right hemothorax []. Patient was pushed to the angiography suite to perform an immediate catheter angiography and intervention. Initial angiography showed no contrast extravasation arising from the subclavian and its branches or the intercostal arteries from the right second to fifth intercostal arteries. With the negative findings, the femoral vein was cannulated to check the pulmonary arteries. A right pulmonary arteriography showed contrast extravasation from the terminal part of the apical branches of the right superior pulmonary artery []. A selective cannulation was done with a 4Fr Cobra catheter. The 4Fr catheter was used instead of a microcatheter because we were able to selectively cannulate the specific arterial bleeder. A total of 3 ml of 1:1 NBCA (n-Butyl cyanoacrylate) and lipiodol mixture was injected. Glue was injected into the bleeder track that communicated with the pleural cavity and at the arterial bleeder point to ensure a good seal. The bleeding stopped immediately post-embolization, evident by post-angiographic run []. The patient had a chest tube put to drain the hemothorax and survived the complication. A repeat CT angio (CTA) study a week later revealed no active bleeding and affected only a small region of the right upper lobe lung parenchyma.
A 36-year-old gravida 5 para 3013 was referred to our fetal treatment centre at 24 weeks of gestation with a fetal diagnosis of congenital high airway obstruction syndrome (CHAOS) without additional anomalies (). Fetal imaging revealed a gap in the trachea, but sufficient tracheal length was present to permit access for tracheostomy. Fetal cytogenetics from an amniotic fluid sample revealed a normal karyotype and microarray. In a multidisciplinary conference involving the family, options were discussed to include termination of pregnancy, delivery with neonatal comfort care and an EXIT-to-airway procedure. The family was well informed that without an established airway at the time of delivery, a neonatal demise would be imminent. Fetoscopic laser decompression of CHAOS, feasible in select cases, was not considered in this scenario secondary to the long gap defect noted on fetal imaging, which would result in a low likelihood of a successful procedure, as well as the associated risks of surrounding tissue injury. Prematurity is also higher following fetoscopic procedures, and an EXIT procedure remains necessary regardless of decompression to develop an adequate airway at delivery. The family elected for a re-evaluation in the third trimester and returned at 31 weeks of gestational age for a repeat ultrasound and fetal MRI. She received weekly ultrasounds at the referring centre to determine fetal viability, monitor amniotic fluid volume and assess for signs of premature labour until she relocated to our centre. Findings on follow-up remained stable when compared with her earlier evaluation, with the exception of asymptomatic polyhydramnios.\nAfter follow-up counselling, the family elected to undergo an EXIT-to-airway procedure scheduled for 37 weeks of gestation. At this point, a call tree was established placing all key specialties on 24-hour availability until the procedure was completed. The gestational age chosen for the procedure was established to allow for further fetal growth and to promote fetal lung maturity.\nAt 34 weeks 5 days of gestation, she presented to labour and delivery at 03:00 on a Sunday morning with the complaint of gross rupture of membranes. On examination, her cervix was noted to be 4 cm dilated; there was gross pooling of amniotic fluid; and the umbilical cord was prolapsed through the cervix up to the level of the introitus (). The fetus was in the breech presentation. Contractions were occurring regularly at 4 min intervals with persistent variable fetal heart rate decelerations down to 80 beats/min. The call tree was activated. The patient was taken to the operating room and underwent general anaesthesia with endotracheal intubation, while the multidisciplinary team congregated to discuss adjustments to the procedure. The time from patient presentation in labour and delivery triage to induction of general anaesthesia was 59 min, with all essential team members present.\nThe decision was made to make a maternal midline laparotomy to provide sufficient access to completely exteriorise the late-preterm gravid uterus and to make a fundal hysterotomy to deliver the fetal head and neck first. The placenta was anterior, and the fetus was in the breech presentation in the setting of anhydramnios secondary to rupture of membranes. An attempt at external cephalic version was not deemed safe in the setting of anhydramnios, active labour and existing cord prolapse. For these reasons, the original plan to perform a maternal abdominal transverse skin incision with a low transverse uterine hysterotomy was therefore abandoned. The midline skin incision was made to just below the umbilicus with placement of a large Olexis O retractor (Applied Medical, Rancho Santa Margarita, Californis, USA) allowing the uterus to be exteriorised. The anaesthesiologist provided maximal halogenated agents with a mean alveolar concentration of 3, along with both nitroglycerin and terbutaline. Unfortunately, uterine relaxation was not sufficient to maintain optimal placental perfusion to the fetus. In an effort to expedite the procedure, the surgical team proceeded by placing a haemostatic myometrial box stitch at the fundus placed well away from the placental edge. The uterus was incised within the box stitch with electrocautery, and the amniotic sac was entered. Bainbridge clamps were used to compress the myometrium prior to placing uterine haemostatic staplers. Due to inadequate uterine relaxation, the thickened myometrium prohibited sufficient compression of tissue to allow for stapling. At this point, the uterine entry point was extended with electrocautery, and Allis clamps were used along the length of the hysterotomy to provide haemostasis. The fetal head and neck were then delivered followed immediately by an intramuscular injection of a cocktail containing atropine, rocuronium and fentanyl. A rapid intravenous infusion device was used to infuse warm lactated Ringer’s solution through the hysterotomy to assist in maintaining uterine volume. Fetal monitoring performed throughout the procedure by fetal cardiology demonstrated intermittent bradycardia with rate as low as 88 beats/min and as high as 129 beats/min with depressed biventricular function. At this time, the paediatric surgeon and paediatric otolaryngologist worked in concert and established an airway via an endotracheal tube through a tracheostomy incision. The time from delivery of the head and neck until airway establishment was 3 min. The remainder of the baby was delivered; the umbilical cord was clamped and cut; and the infant was passed off to the neonatology team.\nThe neonatal response to initial resuscitation was an immediate return to a heart rate in the 150’s bpm with an oxygen saturation of 100%. After stabilisation, bronchoscopy revealed laryngeal atresia below the level of the vocal cords with an intact trachea ().\nThe parturient was extubated after the placement of bilateral transversus abdominus plane blocks for postoperative pain control. Unfortunately, during the first 24 hours postpartum, the mother developed uterine atony necessitating the use of uterotonics and uterine balloon tamponade. She received a transfusion of 2 units of packed red blood cells. Subsequently, the mother remained inpatient for three postoperative days and was discharged in good condition without further complications from the surgical procedure.
A 15-year-old female with no significant past medical history presented after being struck in the face by a ball while playing water polo. The patient felt pain in her jaw, which was the chief complaint when she presented to the emergency department. Upon neurological assessment, the patient complained of midline tenderness from the skull base to midline cervical spine over C3; denied headaches, changes in vision, speech or swallowing, extremity weakness or paresthesias. A maxillofacial computed tomography (CT) scan did not show evidence of an acute facial fracture. However, the CT scan did reveal a radiolucent, ovoid-shaped lytic lesion arising in the left lateral mass of C1, between the anterior tubercle and the transverse process. Magnetic resonance imaging (MRI) studies further confirmed an enhancing osseous lesion at the left lateral mass of C1, with cortical breach and extension into the left lateral atlantodental joint space (). Of note, three years prior, patient had a CT cervical spine which, upon retrospective review, demonstrated a similar but much smaller lesion.\nDifferential diagnoses underlying this vertebral cortical erosion included those of infectious etiology, as well as oncologic lesions, such as giant cell tumor of bone, aneurysmal bone cyst, osteoblastoma, osteosarcoma or even Langerhans histiocytosis (LCH). Oncology recommended that the cervical spine lesion be biopsied for tissue diagnosis. Due to the unusual location of the lesion and risk of locally aggressive pathology, or possible tumor seeding along the biopsy track, interventional radiology was unable to perform a CT guided needle biopsy. It was therefore decided that the patient would require open neurosurgical biopsy for diagnosis.\nDue to the anterior and lateral location of the vertebral lesion, an anterior transoral approach to the C1 lesion was performed, in order to obtain a sufficient amount of the contrast enhancing component of the mass for pathologic diagnosis. The transoral approach was performed in a multidisciplinary fashion, during which the otolaryngology team used direct visualization, as well as stereotactic navigation, to expose the C1 anterior tubercle on the left side. Once exposure was completed, neurosurgery team utilized a matchstick burr to then drill the anterior outer cortex of C1. Multiple specimens from the fibrous tumor were taken, with curettes and pituitary forceps.\nThe sampled tissue did not show features of osteoblastoma or osteosarcoma, nor were there features of LCH or signs of infection. In the sampled region, the lesion consisted of a proliferation of nondescript stromal cells with intermixed multinucleated giant cells, and occasional clusters of foamy histiocytes (). Special testing for giant cell tumor of bone (G34W staining) was negative, as was fluorescence in situ hybridization (FISH) testing for Ubiquitin Specific Peptidase 6 (USP6), making a primary form of aneurysmal bone cyst unlikely. However, due to the aggressive nature of the patient’s osteolytic lesion and the significant risk for atlantoaxial instability associated with its location, it was decided to start the patient on Denosumab. Denosumab is an osteoclast inhibiting pharmaceutical agent, which was administered to the patient in order to stabilize and consolidate the lesion. Samples of the patient’s lesion were also sent out to a nationally recognized expert bone pathologist, whose findings were most consistent with benign giant cell rich lesion with histiocytes.\nThe patient was re-assessed three months postoperatively and MRI studies revealed that there was no interval decrease in the size of the tumor. In fact, there was a slight progression of the lesion anteriorly, despite treatment with Denosumab. After presenting the patient’s case at our institution’s multidisciplinary tumor board, it was decided to offer the patient a gross total resection of the offending lesion. This would inherently lead to significant atlantoaxial instability, therefore a posterior occiput to cervical three instrumented fusion was also warranted.\nThe transoral approach was performed in a multidisciplinary fashion, during which the otolaryngology team used direct visualization as well as stereotactic navigation, to expose the cervical vertebrae through the posterior pharynx. Fibrous tumor was identified and dissected until superior, inferior, and lateral margins of tumor resection were confirmed grossly, with fluoroscopy, and neuronavigation. Additional C1 anterior tubercle eccentric towards the right side was also taken, to include a normal bony margin. A small rim of tumor adherent to the vertebral artery was left behind. After the otolaryngology team closed the posterior pharynx, the patient was carefully turned prone, maintaining spinal precautions. Base of the occiput to cervical three was then exposed. C2 pedicle screws were placed. C3 lateral mass screws were placed. An occipital plate was sized. Screws into the occiput were placed. Fluoroscopy confirmed excellent position and spinal alignment. There were no post-operative complications and the patient was discharged home in good condition. Pathologic examination of the resected material at this time showed complete disappearance of the giant cells, due to Denosumab therapy, with the remaining lesional tissue resembling benign fibrous histiocytoma (). Post-operative imaging studies revealed a stable posterior cervical spine construct, along with minimal rim-enhancement along the vertebral artery, as expected (). At a three-week follow up visit in clinic, the patient’s incisions were healing well, she was neurologically intact, tolerating regular diet, and was eager to return to school.
A 47-year-old man was admitted to his local hospital complaining of left abdominal pain. CT showed a 10-cm tumor in the left abdomen, and he was referred to our hospital. Contrast-enhanced CT confirmed a 10-cm hypodense solid mass in the retroperitoneum of the lower left abdomen. It showed that the tumor was contiguous with the third lumbar nerve, suggesting that it was a schwannoma (). Because the tumor was huge and its presence seemed to be associated with abdominal symptoms, we planned to resect it via less-invasive laparoscopic surgery.\nAs the tumor was close to the left ureter and testicular arteries and veins, there was concern about their injury. Hence, we constructed a 3D CT image preoperatively to understand its anatomical positioning and surroundings (). In addition, to avoid left ureter injury, we placed a fluorescent stent in the left ureter preoperatively.\nWe then undertook five-port laparoscopic surgery using an infrared imaging videoscope. Two 10-mm ports were placed on the cranial side of the umbilicus and in the lower right abdomen, respectively, and three 5-mm ports were placed, respectively, on the left and right upper abdomen and the cranial side of the pubis. The tumor was on the dorsal side of the sigmoid colon in the lower left abdomen (). We could then perform the dissection along the tumor, clearly visualizing the left ureter () and the left testicular arteries and veins (). Finally, the third lumbar nerve continuous with the tumor was dissected near the tumor (), and the tumor was removed from an umbilicus wound that extended 7 cm. Total operative time was 248 min, with an estimated blood loss of 29 ml. The surgical specimen was soft and spherical, with a capsule of 10 cm maximum diameter. The specimen contained a septum that was filled with a dark-red serous fluid ().\nPostoperatively, the patient experienced femoral nerve palsy, but it diminished over time because of rehabilitation. He was discharged from the hospital on postoperative Day 6.\nHistologically, the tumor showed irregular formation with spindle cells and foci of foam cells. Immunostaining for S-100 protein was positive (). Based on these findings, schwannoma was diagnosed.\nCurrently an outpatient, he is free from abdominal symptoms. We plan to follow him with CT imaging to check for signs of recurrence.
A 15-year-old boy originally from Somalia underwent routine TBC screening on arrival in Norway. Half a year earlier, he had a transient episode with malaise and fever, with no identified underlying cause. On the time of the TBC examination, he had no cough, fever, weight loss, or night sweats. Both the tuberculin skin test by the Mantoux method and Quantiferon GOLD test turned out positive. He was not previously vaccinated for TBC. X-ray of the chest revealed a 10 mm lesion in the right lung (). There were no acid-fast bacilli detected on microscopic examination of smears from induced sputum, and the culture later proved negative. Pending culture results, he was started on basic TBC treatment with rifampin, isoniazid, pyrazinamide, and ethambutol. After the initiation of treatment, he felt unwell with nausea and anorexia.\nFifteen days later, he was admitted to the hospital with acute left hemiparesis. Computed tomography (CT) of the brain showed a cerebral infarction in the right hemisphere (). Doppler ultrasonography of the cervical vessels showed a marked, homogenous, circumferential thickening of the vessel walls in the right and left common carotid artery. There was no calcification of the vessel walls. There was a stenosis of the caudal part of the right common carotid artery and a poststenotic flow with low velocities in the medial and cranial part of the vessel, while the left common carotid artery was occluded (). The vessel walls were normal in the internal and external carotid arteries on both sides. A retrograde flow was seen in the left external carotid artery, while a slow antegrade flow was detected within the left internal carotid artery. The vertebral arteries were open with high flow velocities, but no signs of stenosis. Spiral CT angiography demonstrated a high-grade stenosis of the origin of the common carotid artery on the right side, whereas the common carotid artery on the left side was occluded (). The internal and external carotid arteries appeared normal on both sides. The subclavian and vertebral arteries as well as the arteries of Willis circle had normal contrast enhancement. Echocardiogram and transthoracic and transesophageal echocardiography were normal. There were no bruits over the heart or the neck. The patient had full pulses in the radial arteries, with normal and symmetrical blood pressure in the arms. He had previously suffered a bilateral below-knee traumatic amputation. Due to multiple metal fragments in his stumps, magnetic resonance imaging (MRI) was not performed. During the first week of hospitalization, he complained of pain in his legs. CT of the legs showed no abscesses, and, with the theory of phantom pain, treatment with gabapentin was initiated with good pain relief. Blood tests showed a slightly elevated ESR of 18 mm/h and a CRP of 25 mg/L. The analyses were otherwise normal with respect to hemoglobin, leucocytes and platelets, international normalized ratio (INR), activated partial thromboplastin time (APTT), anti-neutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), antinuclear antibodies (ANA), and anticardiolipin antibodies. Blood culture showed no growth of aerobic or anaerobic bacteria, HIV test was negative, and Treponema pallidum was not detected neither in the blood nor in the cerebrospinal fluid. Lumbar puncture showed an opening pressure of 17 cm H2O with clear and colorless cerebrospinal fluid, with normal amount of cells counts, total protein, and glucose.\nTreatment with aspirin was started at admittance. The raised ESR and CRP in addition to the findings on ultrasonography and CT angiography raised suspicion of vasculitis. Therefore, treatment with prednisolone was also initiated, augmented a few weeks later with methotrexate. One year thereafter, the Doppler ultrasonography findings were unchanged. Two years after the stroke, he still had a hemiparesis but developed no new clinical signs or symptoms.
This 33-year-old male carpenter by profession in an industry started consuming alcohol since year 1999. Initially, he used to drink with peers in moderation and on social occasions. Gradually he increased his consumption over next 6 years in frequency and quantity to around 180 mL rum four to five times a week with features of dependence in craving, loss of control, tolerance, daytime relief drinking, and withdrawal tremors and restlessness on abstinence. Year 2006 onwards he started consuming vodka as he found it to be odorless and thus could take to his place of work mixed in water without getting caught. Gradually, he increased it to 360–480 mL five to six times a week regardless of the advises by the relatives and family members to reduce his consumption. This pattern continued till Jan 2011 when he had to suddenly abstain from alcohol due to non availability of vodka in his village. He had strong craving and did not feel like eating during the next 7 days. After a week he finally was able to procure vodka from the city and consumed around 360 mL. Next day onwards he developed sudden onset blurring of vision and diminished perception of colors and depth. He consulted local practitioner who advised him to stop alcohol but he continued to consume owing to strong craving and its withdrawal effects. The visual disturbance worsened over next 3–4 weeks. At work he was unable to see clearly, which was noted by people necessitating referral to tertiary care centre. Further history at psychiatric centre revealed excess consumption of tobacco for last 5 years (ie, up 60 gm/week). Family history revealed regular consumption of alcohol in his father. Evaluation on admission revealed elevated systolic blood pressure, tachycardia, tremulousness of body, moist cold palm, perception of only hand movement both eye, subtle cerebellar sign in dysmetria, and dysdiadochokinesia (left side) and tingling and reduced fine touch sensation both lower limb below knee. Investigation revealed mean corpuscular volume 97 fl, gamma glutamyl transferase-97 IU/L, and Bilirubin 2.1 mg%, ultrasonography abdomen was normal. Evaluation by neurologist revealed no localizing pathology requiring specific neurological intervention. Ocular coherence tomography revealed normal fundus, reduced flash visual evoked potential (VEP) P100 latency in both eyes, and bilateral temporal thinning of retinal nerve fiber layer on temporal quadrant both eyes, possibly due to toxic etiology. Psychometric evaluation revealed high perseveration on Wisconsin card sorting test and mild impairment in visual retention and recognition on the post graduate institute memory scale. He was managed with forced abstinence, vitamin supplementation, and detoxification with tapering doses of chlordiazepoxide. Gradually his subtle neurological signs and symptoms improved over 1 week along with improvement in withdrawal symptoms. He was also managed by ophthalmologist for his visual symptoms. Visual acuity that was initially limited to hand movements improved to 6/12 to 6/18 both eyes. He was also noted to have constriction of field of vision and had his color vision was noted to be colour perception IV that continued throughout his period of admission. He was further given psychoeducation, counseling, group therapy all aimed at relapse prevention and anticraving treatment Tab Baclofen XL 30 mg hora somni that he tolerated well. Presently he is asymptomatic from psychiatric side and motivated for further abstinence. He slowly resumed his carpentry work but required brighter lighting in his place of work.
We present the case of a 36 year old G4P4 Hispanic female who presented to the ED for nausea, vomiting, diarrhea, 30 pound weight loss over 2–3 months, generalized body aches most pronounced in the lower back for 5 days, and a positive pregnancy test. Past medical history was significant for hypertension, dysphagia, 4 caesarean sections and bilateral tubal ligation. Family history was noncontributory. She denied tobacco, alcohol, or intravenous drug abuse. Physical exam revealed reproducible pain upon palpation of the spine. The bimanual exam was negative for discharge, cervical motion tenderness, or pelvic tenderness. A routine urine pregnancy test was positive and subsequent serum testing demonstrated a β-hCG level of 154 mIU/ml. The patient denied sexual intercourse in over 2 years and confirmed having a normal menstrual period less than 2 weeks prior. The patient was admitted to the hospital for further assessment and management. Initial abdominal and transvaginal ultrasound examination revealed no intrauterine pregnancy, non-visualization of the right ovary, and a complex cyst measuring 3.5 cm in diameter on the left ovary. Her repeat serum β-hCG 48 hours later was 155 mIU/ml demonstrating an insignificant change from the earlier reading. A Computed tomography (CT) scan with contrast of the thorax showed clear lungs and a cluster of enlarged lymph nodes in the celiac axis, with the largest being 1 cm. The patient was consented for laparoscopic evaluation, bilateral salpingectomy, possible left ovarian cystectomy, peritoneal washings and dilatation and curettage. At time of surgery, pelvic washings were collected and they were negative for malignant cells. Review of the pelvis revealed normal anatomy. The cyst on the left ovary was removed and sent for frozen section pathology that revealed a hemorrhagic corpus luteal cyst. The uterine curretings were also sent for frozen section pathology that showed late secretory endometrium and no chorionic villi. The patient had a normal postoperative course and was discharged from the hospital on the first postoperative day.\nUpon discharge, her serum β-hCG level was 175 mIU/ml. The final pathology report on the left corpus luteum cyst located a small focus of moderately differentiated adenocarcinoma in corpus luteum staining strongly positive for Cytokeratin 7 (CK7) and negative for Cytokeratin 20 (CK 20) suggesting a primary gastric or pancreatic carcinoma. The patient was referred to the oncology service. Magnetic resonance imaging (MRI) of the pelvis/abdomen demonstrated left para-aortic and paraceliac adenopathy, likely metastatic in nature. No discrete masses were seen in the ovaries. Bone scan showed enhancement in the right pedicle of L3 vertebra highly suspicious for metastasis. At this point, the patient reported increasing abdominal and back pain. Her laboratory investigation was significant for CA-125 of 134 U/ml (reference range: 0.0-21.0), CEA level of 37.2 ng/ml (reference range: 0.0-10.0), and CA 19–9 3230 U/ml (reference range: 0–37). Computed tomography (CT) guided fine needle aspiration and core biopsy of the L3 vertebral body were positive for malignant cells of poorly differentiated metastatic carcinoma, strongly positive for β-hCG, α-inhibin, and human placental lactogen (HPL). Multiple biopsies collected at colonoscopy and esophagogastroduodenoscopy showed a poorly differentiated adenocarcinoma in the lamina propria of the stomach fundus positive for AEI/3, CD7, CK20 and CEA (Figure ). The esophageal biopsy showed atypical cells with necrotic exudates and the colon biopsy showed no malignancy. The patient underwent 2 weeks of radiation therapy on the L3 lesion and was readmitted to hospital for pain control and supportive services for her bilateral lower extremity weakness.\nTherapeutic intervention with chemotherapy was contraindicated as the patient was found to have urosepsis. A repeat CT abdomen/pelvis showed widely metastatic gastric adenocarcinoma with possible compression of cauda equina at L3 and metastases to the liver, spleen, left adrenal, and left acetabulum (Figure ). In addition, the CT image revealed peritoneal carcinomatosis, retroperitoneal and mesenteric adenopathy, left hydronephrosis secondary to compression by metastatic adenopathy, acute pancreatitis and splenic vein thrombosis. During hospitalization the patient expired secondary to urosepsis, disseminated intravascular coagulation, and widespread metastatic disease.
A four-day-old male newborn was transferred to the Seoul National University Hospital on account of progressive necrotic skin lesions. He was delivered via cesarean section due to prolonged labor at a gestational age of 39 weeks + 2 days with a birth weight of 3560 g. The patient was an only child with no remarkable prenatal or perinatal problems, including intrauterine sonography findings. Both parents denied a family history of hematologic or autoimmune diseases (Fig. A). He was initially treated with antibiotics under the impression of neonatal sepsis due to necrotic skin change at an outside hospital; however, his skin lesions worsened. The skin lesions started at the toes and rapidly progressed to the lower legs, buttocks, left hand, and left upper arm. The lesions were initially dark red and then changed to black (Fig. ).\nOn the sixth postnatal day, he abruptly experienced several episodes of apnea accompanied by desaturation, from which he soon recovered. Although he did not show motor deficits, his right pupil was unresponsive to light, and this was followed by clonic movements in both arms for a few seconds.\nBrain sonography and computed tomography images showed multifocal patchy intracranial hemorrhage in the right cerebral hemisphere and left temporo-occipital area, and intraventricular hemorrhage without ventricular dilation. Moreover, an old ischemic lesion, which was thought to have occurred in the uterus, was observed on the left periventricular white matter (Fig. A, B). Brain magnetic resonance imaging (MRI) and brain sonography images did not reveal venous thromboembolism (Fig. C). Venous sonography images showed thrombotic occlusion of the left cephalic vein, but not of the internal organs and veins, such as the kidney, liver, spleen, pancreas, and portal vein. Electroencephalography showed intermittent, slightly suppressed background activity and occasional spike discharges, which suggested diffuse cerebral dysfunction and focal seizures.\nThe complete blood count, liver function test, and renal function test results were unremarkable except for hyperbilirubinemia, which was thought to be due to physiologic jaundice. The levels of inflammatory markers were not elevated, and microorganisms were not isolated in the blood, urine, or cerebrospinal fluid. The prothrombin time international normalized ratio (PT-INR), activated partial thromboplastin time (aPTT), and D-dimer levels were 0.99 s, 33 s, and 23.05 μg/ml, respectively (Table ). The protein C activity level was remarkably decreased below 10% (normal range: 74–152%); however, the protein S concentration was within the normal range. A skin biopsy of the left calf skin lesion showed fibrin clots in most capillaries, suggesting DIC or deep vein thrombosis.\nMolecular analysis was performed targeting inherited diseases presenting as early-onset vasculitis or coagulopathy. The results revealed a homozygous pathogenic variant c.631C > T (p. Arg211Trp) in the PROC gene, which was inherited from both his unaffected parents (Fig. B). This variant is seldom present in the population database (rs121918143, ExAC 0.02%) and has already been observed to be a compound heterozygous variant in individuals affected by purpura fulminans and severe protein C deficiency []. Both parents showed no clinical signs of heterozygous mutation; the father and mother showed protein C activity levels of 69 and 57%, respectively (normal range, 74–152%).\nThe patient was initially treated with intravenous prostaglandin E1, high-dose steroids, intravenous immunoglobulin with antibiotics, and nitroglycerin ointment to prevent skin necrosis prior to the diagnosis of severe protein C deficiency. Antiepileptic drugs and mannitol were added to prevent further seizures and decrease the intracranial pressure, respectively. Under the diagnosis of protein C deficiency, fresh frozen plasma (FFP) transfusions (10 ml/kg/day) were started.\nAs new skin lesions were found on the left arm and both buttocks on postnatal day 7, low-molecular-weight heparin (LMWH) treatment was started. Protein C concentrate replacement therapy was initiated on postnatal day 11. The first dose of protein C concentrate was 100 IU/Kg, followed by 50 IU/Kg every 8 h. The doses of protein C concentrate were adjusted according to protein C activity level and clinical symptoms. The target level of protein C activity was 50% and the dose of protein C concentrate was increased if the existing necrotic skin lesions were aggravated or a new lesion was developed. As a result, protein C concentrates were given up to 80 IU/kg every 8 h. The immediate level of protein C activity after 1st loading of protein C concentrate was 47%, and the final trough level was 55% on postnatal days 12 and 17, respectively. The level of D-dimer was decreased to 5.13 μg/mL after protein C concentrate replacement but was not normalized. From postnatal day 17, anticoagulation therapy was changed to warfarin instead of protein C replacement and heparinization therapy. The target PT-INR was 2.0 to 3.0 [].\nAfter 2 months of treatment, the patient’s skin lesions healed without any surgical treatment but remained scarred with shortened toes (Fig. A–C). There were no more clinical seizures, and follow-up brain sonography and brain MRI did not show any new hemorrhagic brain infarctions; however, there was ongoing loss of ischemic tissue (Fig. D, E). Ophthalmic surgical interventions were performed to treat bilateral retinal traction detachments with retinal folds. Finally, the patient was discharged on postnatal day 87 with warfarin and other medications.
A 68-year-old man presented with a progressive painless swelling of his left leg. Past medical history revealed an ipsilateral proximal tibia and fibula fracture 40 years before; the tibial fracture was treated then with an open reduction and internal fixation with a plate and screws. Since then, he experienced a postoperative deficit of the left common peroneal nerve. Two years before, after a minor injury (a muscle strain) to the same leg, he noticed a palpable, painless mass that had increased in size substantially over the last five months.\nPhysical examination at presentation showed a palpable extra-osseous mass at the anterior aspect of the left leg; the mass was not adherent to adjacent soft-tissues and bone, and it was tender but painless to palpation. The skin was dry and not erythematous. Dorsiflexion of the left foot was weak secondary to the known left common peroneal nerve deficit. Radiographs of the left leg showed extensive calcification at the soft-tissue of the anterior and posterior leg ().\nComputed tomography (CT) scan of the left leg showed a calcified fusiform soft-tissue mass with peripheral plaque-like calcification linearly oriented through the muscles of the anterior and posterior leg and extending through the interosseous membrane ().\nLaboratory studies were within normal values. To exclude malignancy, an ultrasonography-guided trocar biopsy was done. Histological sections of the biopsy specimens showed multiple fragments of pultaceous s and partially calcified tissue, presence of sclero-hyaline and necrotic tissue with calcifications without any vital cells; histological findings were indicative of the diagnosis of calcific myonecrosis ().\nThe patient was informed of the benign entity of the lesion. Given the known high rate of complications, he was recommended for no further treatment except for clinical and imaging observation. Located at the site of the biopsy, he experienced infection with drainage that eventually healed after six months with antibiotics and wound dressing changes. During the last follow-up examination, two years after diagnosis, the patient experiences no noticeable increase in the size of the mass, and diminished pain. Repeat radiographs of the leg were similar to those at presentation. He was advised to continue full activity and to monitor his leg for new symptoms or mass enlargement.
A 34-year-old female with past medical history of sickle cell trait presented to her gynecologist with bilateral palpable breast masses. She was referred for bilateral mammograms and sonograms which revealed a 4.2 × 2.2 × 3.2 cm irregular right breast mass and 1.3 × 1.0 × 0.8 cm left breast mass, highly suspicious for malignancy. She underwent ultrasound-guided core biopsies of both lesions which showed infiltrative, poorly differentiated carcinoma (). Immunohistochemistry performed for estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 were negative and Ki67 proliferative index was approximately 70%. At this time, the patient was referred to the oncology clinic. The patient underwent bilateral breast magnetic resonance imaging (MRI) which revealed multiple suspicious enhancing masses in all four quadrants of the right breast, a possible right pleural based enhancing mass and multiple suspicious masses in the left breast (). She was sent for Computed Tomography (CT) of the chest with intravenous contrast to evaluate the pleural mass and was discovered to have multiple pulmonary nodules. A CT-guided fine needle aspiration of a 1.9 × 1.2 cm right lower lobe lung nodule showed malignant cells similar to those from the breast biopsies. Subsequent bone scan revealed multifocal osseous disease involving the thoracic, lumbar spine and right ischium, acetabulum and superior ramus. Options for systemic chemotherapy for the treatment of metastatic triple negative breast carcinoma were discussed at this time.\nPrior to treatment, she underwent contrast enhanced staging CT of the abdomen and pelvis which revealed a 6.7 × 6.9 cm mass arising from the lower pole of the right kidney (, ). Given the patient’s young age, history of sickle cell trait, radiologic findings of a large renal mass, multiple lung and breast nodules as well as the histological picture, the diagnosis of metastatic renal medullary carcinoma was considered. At this time, the original breast core biopsies were re-reviewed. Histological findings of prominent neutrophilic infiltrate closely associated with the tumor and sickled erythrocytes were identified. An additional immunohistochemical panel of PAX 8, vimentin, gross cystic disease fluid protein (GCDFP), Oct 3/4 and INI1 (BAF47) was performed. Positive expression of PAX 8 (nuclear) (), vimentin (cytoplasmic and membranous), Oct3/4 (nuclear) () and loss of INI1 expression () in tumor cells confirmed the diagnosis of renal medullary carcinoma metastatic to breast [-].\nThe new diagnosis of metastatic renal medullary carcinoma was discussed with the patient. Retrospective review of outpatient medical records did reveal microscopic hematuria dating eight months prior to her diagnosis. At this time her poor prognosis was discussed and she opted for systemic chemotherapy. She was started on carboplatin and gemcitabine and achieved a partial response after two cycles with regression of the kidney tumor and lung lesion. After four cycles she developed progressive osseous metastatic disease with stable systemic disease and required radiation to her right hip. She then developed spinal cord compression requiring radiation as well as systemic progression of disease. At this point she was switched to weekly paclitaxel and received four cycles before her performance status declined and she died of disease progression twelve months after initial diagnosis.
A 75-year-old male presented with radicular pain in his left leg. The disabling radicular pain started 2 weeks earlier with no prior trauma or other known causal factors. He had been taking metformin for diabetes mellitus, but no anticoagulants. His medical history included an endoscopic mucosal resection for early gastric cancer 6 years before presentation. Lower back pain also preceded his current symptoms and had been treated conservatively with intravenous ketamine and midazolam.\nOn physical examination, motor strength was 4 out of 5 for left knee extension and foot dorsiflexion, with no measurable atrophy. The patient had severe radiating pain and hyperesthesia in the 4th and 5th lumbar dermatomes. His straight leg raising test and deep tendon reflex were negative. Coagulation parameters were within the normal range. Plain radiographs of the lumbar spine revealed spondylotic changes, but no instability. Computed tomography (CT) showed bony erosion and a punched-out lesion at the left 5th lumbar facet joint and an extradural mass. Magnetic resonance imaging (MRI) showed a sharp-margined mass with mixed signal intensity eroding the adjacent vertebral body. The mass severely compressed the thecal sac and root (). The patient underwent surgery in the prone position. The lesion was accessed via a paramedian intermuscular approach, and a transforaminal corridor was formed with a facetectomy of the 4th inferior lumbar facet and medial part of the 5th superior lumbar facet. The articular surface of the facet joint was discolored by a hematoma with a dark brown color. We identified an extensive hematoma between the two layers of ligamentum flavum which extended to the epidural space (). The old form of hematoma has more elasticity than usual spinal epidural hematoma. The tough capsule containing the hematoma was connected with the facet joint between the fourth and fifth lumbar vertebra. After removing a large amount of the hematoma and capsule, we could identify the adjacent root and thecal sac. The entire procedure was performed while preserving the spinoligamentous structure at the midline. To prevent instability subsequent to the facetectomy, a pedicle screw was fixed through the intermuscular windows. The percutaneous screw was inserted to the contralateral side. Microscopic examination of the surgical specimen comprising a hematoma and cyst membrane revealed an old cystic lesion with signs of subacute bleeding. Fibrocollagenous tissue with widespread fresh blood and hemosiderin deposits were observed. Chronic inflammation with neovascularization and myxoid degeneration were also present (). Alcian blue stain demonstrated the presence of mucin within the hematoma (). However, there was no evidence of a synovial lining. The final diagnosis was a hemorrhagic ganglion cyst. Postoperatively, the patient's symptoms and neurological function improved markedly. Follow-up plain radiographs showed no iatrogenic instability or collapse. MRI showed shrinkage of the hematoma and decompression of the dural sac (). During the 2 years of follow-up period, patient had no additional symptom or recurrence.
A Thai male patient, aged 46 years, presenting with chronic abdominal pain for 3 months. He frequently visited hospital in 3 months about chronic abdominal pain with unidentified cause—recurrent hyponatremia. He underwent upper gastrointestinal endoscopy and ultrasonography of upper abdomen but showed within normal limit of both examinations, so he was treated as chronic dyspepsia and symptomatic treated about hyponatremia but he still not improves. In admission day, he re-visited hospital with abdominal pain and his blood chemistry showed hyponatremic hypokalemic metabolic alkalosis, so gastric outlet obstruction was provisional diagnosis. Saline loading test showed delayed gastric emptying time. Patient was sent for computed tomography of abdomen because previous upper gastrointestinal endoscopy showed normal study. Computed tomography resulted in 5 cm long, enhanced wall thickening at duodenojejunal junction in left lower abdominal region, abutting adjacent sigmoid colon with preserved fat plane separation and markedly dilatation of the proximal duodenum and stomach is detected as in Fig. . The diagnosis of obstructed proximal jejunum was made and exploratory laparotomy was decided. In operative field, a 5 cm Cauliflower mass at proximal jejunum, 15 cm distal to ligament of Treitz, causing proximal duodenal dilatation and distal small intestines collapse was found as in Fig. . No liver, omental or peritoneal nodule was found. Radical segmental proximal jejunal resection (with 5 cm proximal and distal margins, with mesentery that vascular supplied resected jejunal segment) with primary small intestinal anastomosis was done. Operative time was 48 min and estimated blood loss was 50 mL. After operation, patient fully recovered but superficial surgical site infection was found and pus culture showed Proteus mirabilis and Escherichia coli. Pathologic examination showed well differentiated adenocarcinoma of jejunum with extension into perienteric fatty tissue, free all resected margins, and reactive hyperplasia of three lymph nodes. The diagnosis of Adenocarcinoma of the jejunum (pT3N0M0—stage II) was made and patient was referred to the oncologist for possibility of adjuvant therapy but the oncologist decided not to give patient adjuvant therapy. Patient remains healthy after 9 months of operation.
A 49-year-old Caucasian man presented to the local orthopaedic clinic with complaints of pain in the sole of his foot. He was diagnosed with plantar fascitis and was given a prescription for a methylprednisolone dose pack. He complained of vague neck pain on day 2 of therapy. Initially, he ignored the symptoms, but his condition continued to escalate in a generalized fashion. On day 3 of therapy, myalgia and muscle weakness progressed to involve upper arm and thigh muscles, and he did not take the methylprednisolone dose. He was seen on day 4 of therapy by which time his symptoms had progressed to generalized muscle weakness and pain. He stated that he was unable to open his car door because of hand weakness. He also complained of myalgias involving the same muscle groups. He was tender to palpation, and his symptoms did not improve with 500 mg of over-the-counter acetaminophen, which he was taking every six hours. He had no fever, difficulty breathing, flu like symptoms, facial muscle weakness, difficulty swallowing, or urinary or gastrointestinal symptoms. Before the current illness, his medical history was significant for gastroesophageal reflux disease.\nOn examination, his vital signs included blood pressure of 130/85 mm Hg, pulse of 80 beats/min, respiratory rate of 15 breaths/min, temperature of 98.9°F and oxygen saturation of 98% on room air by pulse oximetry. There was pain on palpation of the upper and lower extremity musculature, including the small muscles of the hand. Sensation in cranial and peripheral nerve distribution was normal and symmetric bilaterally. Muscle strength was 2 of 5 in the flexor and extensor groups of the upper and lower extremities. Facial muscle strength was normal. His hand grip was weak, and he had difficulty standing up from a sitting position. His gait was normal.\nNormal deep tendon reflexes were noted. Babinski's sign was absent. He had normal cardiovascular, respiratory and abdominal examination results.\nOn laboratory examination, the patient had levels as follows: creatinine phosphokinase (CPK) of 891 U/L (reference range, 22-198 U/L), alkaline phosphatase (ALP) of 77 IU/L (reference range, 30-120 IU/L), aspartate aminotransferase (AST) of 64 U/L (reference range, 10-40 IU/L), alanine aminotransferase (ALT) of 69 IU/L (reference range, 9-60 IU/L, C-reactive protein (CRP) of 14.86 mg/L (reference range, <5 mg/L), and erythrocyte sedimentation rate (ESR) of 10 mm/hr (reference range, Age/2). Muscle biopsy and electromyography (EMG) were not performed. A basic metabolic panel and complete blood count results were normal.\nHe was sent home with ibuprofen 400 mg every six hours as needed for myalgias and instructions to call if his symptoms worsened. He was seen at a one-week scheduled return visit and reported significant improvement in muscle strength and decreased pain. Examination showed muscle strength of 5 of 5 in all muscle groups. Laboratory examination showed a CPK of 130 U/L, ALT of 82 IU/L and AST of 44 U/L. Urine myoglobin results were negative.\nHe was seen again 30 days after initial presentation and was feeling fine and had resumed his normal active lifestyle, farming. He continues to complain of intermittent foot pain, which is worse with activity, and he takes ibuprofen 400 mg as needed for relief.
A 1-month-old corrected age, male infant weighing 3.4 kg was transferred to our institute because of respiratory insufficiency. He was prematurely born by Caesarean section with a birth weight of 1,070 g at 32+1 weeks of gestation, and was small for gestational age. The patient was admitted for 50 days including neonatal period and treated with O2 for the first 4 days after birth due to pneumonia. There was no evidence of hyaline membrane disease or bronchopulmonary dysplasia on chest radiographs and computed tomography (CT) also. On the physical examination, bronchial breathing sounds were increased with rhonci. Regular heart beats were heard with grade 2 systolic murmur on left upper sternal border. He was diagnosed as secundum ASD in the neonatal period. Echocardiography confirmed secundum ASD (diameter 7×12 mm), right-sided volume overload, tricuspid regurgitation (TR) with a peak pressure gradient of 55 to 60 mmHg, dilated main pulmonary artery (diameter 19 mm) and both pulmonary artery (diameter 11 to 12 mm). When the systolic pulmonary artery pressure was estimated from the peak flow velocity in the TR jet by using the modified Bernoulli equation, his pulmonary artery pressure was 58 to 65 mmHg.\nAt first admission, he was intubated and ventilator care was needed because of progressive respiratory distress. The chest radiographs demonstrated severe collapse of both lung fields at the time (). CT was performed to rule-out other diseases associated with PAH at the corrected age of 1 month. A CT scan showed a collapse in the dependent portion of the right lung and a total collapse in the lower lobe of the left lung. Narrowing of main bronchus and right intermediate bronchus were evident and an intrinsic cause like bronchomalacia was suspected (). Viral culture studies (respiratory syncytial virus, adenovirus, influenza A virus) were done; results were all negative. After conservative management, he was weaned off the ventilator within 2 weeks. The infant was prescribed with heart failure medications (digoxin 10 mcg/kg/day divided by 2, furosemide 1 mg/kg/day divided by 2, spironolactone 1 mg/kg/day divided by 2), and extensive physiotherapy of the lung was performed before he was discharged on the 42nd hospital day.\nHe was hospitalized 3 more times up until the corrected age of 4 months due to recurrent respiratory infection and respiratory distress. We expected catch-up growth and improvement of narrowed airway suspected due to bronchomalasia with patient growth. However, on the 4th hospital admission, he required mechanical ventilation for 40 days due to respiratory insufficiency. Follow-up echocardiograph showed sustained PAH with a TR pressure gradient of 60 mmHg. After he was weaned off mechanical ventilation, a follow-up CT scan was performed at the corrected age of 8 months, which revealed dilated pulmonary artery compressing the left main bronchus and right intermediate bronchus, but showed improvement of consolidation in both lungs and mild improvement of stenosis of the right main bronchus (). Up until the corrected age of 8 months the patient was underweight (5.6 kg) and less than the 3rd percentile of his age.\nTo correct these problems, ASD patch closure was performed at this stage. We recognized that he did not suffer from bronchomalacia because his respiratory distress improved after repair of ASD, and the intrinsic cause of airway compression suspected on initial CT scan was due to intra-pulmonary compression resulting from enlarged bronchial vessels and lymphatics. Postoperative echocardiogram showed improvement of TR with decreased peak pressure gradient (22 to 26 mmHg), immediately after the operation. Postoperative recovery was uneventful and he was extubated on the 3rd post-operative day. He was discharged from the hospital on the 22th postoperative day. The patient is doing well 29 months following surgery and is without any medication. Both lungs appear to be normally expanded, as demonstrated by chest X-ray taken 13 months after the operation (). Postoperative CT was not performed to confirm improvement of bronchial compression, because he did not suffer from any recurrent respiratory infections. At present (3 years and 2 months), he shows catch-up growth with 12 kg of body weight, which is between 3rd and 10th percentile of his age.
A 68-year-old Caucasian woman with hypertension and diabetes type 2 was treated in 2001 because of a mass of unknown histological origin of the right upper leg. She underwent a local resection of the tumor and pathological examination showed a DFSP. It was found to be a DFSP in histological research due to proliferation of atypical fusiform mesenchymal cells, with multinuclear giant cells which were sometimes arranged in rosettes (). Moreover, the immunoprofile showed mainly positivity with vimentin (++), desmin (+), and CD-68 (+) which would mostly fit the diagnosis of a DFSP, a malignant fibrous histiocytoma was in the differential diagnosis. Due to tight surgical margins, a re-resection found place with margins of more than 2 centimetres.\nDuring followup a new mass was discovered at the site of the scar 6 years later. Local surgical excision was performed and pathological examination showed a high grade sarcoma not otherwise specified (NOS), grade III. Histological research showed proliferation of a more cellular tumor process with more and bizarre mitotic figures (). The tumor cells showed, compared to the primary tumor in 2001, less differentiation. The diagnosis of a NOS sarcoma was also based on the immunoprofile which was only positive for vimentin and the previously positive markers were considered negative (CD-68, desmin). After surgical excision the tumor was treated with radiotherapy. Ultrasound of the right groin showed no regional lymph node metastasis (RLNM) and there were no abnormalities seen at the chest X-ray.\nDuring further follow-up a groin mass was found 4 years later. CT examination revealed a large lymph node () without any other evidence of distant disease. An ultrasound-guided biopsy was performed and showed a metastases of the sarcoma. A superficial regional lymph node dissection was performed which showed one positive lymph node out of nine dissected and Cloquet's node negative. Pathological-anatomical study showed a metastasis of a high grade sarcoma NOS (). Until now, further followup with chest X-ray and CT scan showed no abnormalities.
Female white 81 years old retired patient. She underwent total right knee arthroplasty in 2007. On the 4th postoperative day, when leaving the hospital after being discharged, she felt to the ground with trauma in the anterior knee that caused wound dehiscence and exposure of the prosthesis with loss of patellar component. The patient was again hospitalized and underwent aggressive surgical procedure for cleaning and collection of cultures and antibiotic therapy for six weeks to control a local infectious process, multi - sensitive Staphylococcus aureus having been detected. Intraoperatively, resection of 60% of the patella was required due to its fragmentation. The patient recovered well from the clinical point of view, and local infection.\nProgressively during the follow-up, she started to present pain and disability of knee extension due to lateral dislocation of the extensor mechanism to active quadriceps contraction due to the lack of restraint on the local soft parts after surgical debridement. Due to the lateralization of the extensor mechanism, she slowly progressed to medial instability and large valgus opening between 2007 and 2011. The patient did not present any evidence of loosening of the femoral and tibial components of the arthroplasty. The functional limitation became important, and surgical treatment was the option elected.\nIn October 2011 she underwent reconstruction of the extensor mechanism and the medial collateral ligament with homologous graft from a tissue bank using a complete extensor mechanism (quadriceps tendon - patella - patellar tendon - tibial tuberosity) and two flexor tendons to medial ligament complex. A channel in region of the anterior tibial tuberosity was performed to accommodate a "press fit" plug bone graft associated with 4.5- mm cortical screw with washer.\nIntraoperatively it was observed that the tibial and femoral components were fixed and well positioned and exchange was not performed.\nPatient developed an active knee extension at the immediate postoperative period. The post-operative procedures were also similar to those of cases 1 and 2.
A 26-year-old black, male, active duty soldier presented to the ED via emergency medical services for evaluation of bilateral lower extremity weakness. The patient reported that his symptoms began earlier in the morning while he was running with his unit during physical fitness training. Throughout the course of the three-mile run he described being unable to maintain pace and felt weighed down by his legs. At the completion of the training his symptoms worsened and when he attempted to get out of his car, he could not move his legs. Specifically, he reported that he could not move either of his thighs or lower extremities, but maintained motion of his feet and toes. Unable to move, bystanders assisted him to his local clinic where he was assessed and then emergently brought to the ED for continued evaluation.\nUpon initial assessment the patient had a mild tachycardia but with otherwise normal vital signs. Neurological assessment demonstrated intact cranial nerves, absence of cerebellar signs, and preserved upper extremity motor and sensory exams. On examination of his lower extremities, he had 2/5 strength of hip flexion, hip extension, and knee extension. Dorsi- and plantar-flexion of the feet were intact bilaterally. Sensory exam was intact to light touch throughout his lower extremities. Gait was unable to be assessed secondary to his inability to ambulate or stand without assistance.\nHis past medical history was significant only for a dermatitis that was treated with triamcinolone and over-the-counter medications. He did admit to using multiple supplements two to three times daily to boost muscle strength, but took no prescribed daily medications. He denied any other symptoms, recent illnesses, vaccinations, travel, military deployments or prior neurologic symptoms. Family history was significant for systemic lupus erythematosus and an unknown thyroid disorder in his mother, as well as an unknown thyroid disorder in his younger brother. Laboratory investigations were significant for a urine specific gravity of 1.032, a thyroid stimulating hormone level below assay detection, free thyroxine level of 18.8 ng/dL (0.7–1.9 ng/dl), creatine kinase of 501 U/L, aspartate aminotransferase of 55 U/L, alanine aminotransferase of 71 U/L, and phosphate level of 2.2 mg/dL. Importantly, his potassium level was normal at a level of 3.8 mmol/L. Electrocardiogram was significant for sinus tachycardia and left ventricular hypertrophy. After one liter of normal saline, the patient fully regained muscle strength, including the abilities to ambulate without difficulty, perform squats, single-leg stance and jumping jacks.\nGiven complete resolution of symptoms and abnormal thyroid function tests, the patient was discharged with a diagnosis of normokalemic, thyrotoxic periodic paralysis. In consultation, he was initiated on propranolol 10 mg three times daily and methimazole 20 mg daily. Outpatient follow-up with endocrinology was also secured, with subsequent testing demonstrating elevations in free triiodothyronine (FT3) at 12.2 pg/mL (1.7–3.7 pg/mL), thyroperoxidase antibody at 209 IU/mL (0–34 IU/mL), and percent thyroid-stimulating immunoglobulins of 294% (0–139%). A diagnosis of Graves’ disease was made and at follow-up the patient continued to do well. Five months after his initial presentation, he has required only minor adjustments in medication, without any repeated neurologic deficits.
A 65-year-old man referred to the emergency department for evaluation of the lower extremity swelling associated with pain for four days. Physical examination demonstrated an overweight man (BMI 29.6 kg/m2) with extensive pitting edema of the left lower limb from the groin to the knee joint with calf tenderness. Color Doppler ultrasound revealed an extensive DVT involving common iliac, external iliac and common femoral vein as well as superficial femoral down to popliteal vein. He was treated by bed rest, elevation with bandaging of left leg, 6000 IU of low molecular weight heparin subcutaneously twice a day and further evaluation was performed to find the underlying etiology. Investigations including hematological, immunological, biochemical, lipid profile, protein S and protein C were normal. Abdominal and pelvic ultrasound (US) showed incidental finding of severe left hydroureteronephrosis with almost lost of cortical thickness, for that abdominal and pelvic computed tomography (CT) scan revealed marked left-sided hydroureteronephrosis and an impacting stone measuring (18 × 10 × 10 mm) at the level of L5/S1 () with signs of DVT affecting left iliac and femoral vein below the above mentioned region (). Next day percutaneous nephrostomy was performed to decompress the hydronephrotic kidney. He was kept as an inpatient for one week under observation then after discharged home on oral anticoagulation in the form of rivaroxaban 20 mg daily. Six weeks later, color Doppler US showed complete recanalization of the superficial femoral, popliteal as well as the proximal segment of deep veins of the leg but common iliac, external iliac and common femoral veins and proximal superficial femoral vein were still partially thrombosed. Under spinal anesthesia, left ureterorenoscopy showed an impacted stone at the level of iliac vessel pulsation causing edema and external compression of the iliac vessels. Through pneumatic lithotripsy, the stone was fragmented and JJ stent inserted (). Next day the patient discharged home and continued on taking his antithrombotic treatment (rivaroxaban 20 mg). The JJ stent was removed 3 weeks later. Three months after that, Doppler US showed complete recanalization of iliac vessels.
A two months old Saudi Arabian male infant was admitted to the pediatric ward of maternity and children's hospital, Buraidah, Kingdom of Saudi Arabia for the management of multiple ulcers on his face. The ulcers was observed by the parents at the age of one month and progressively increased in size with no history of fever. He was the third child of healthy unrelated boduin Saudi Arabian parents, the mother's age was 35 and the father's age was 40. There was no history of perinatal or postnatal complication. The child was delivered in a tent in the desert where his parents live.\nOn physical examination, there was severe disfigurement of the face with 3 crusty ulcers Surrounded by a notable erythematous reaction, the biggest one presents on the right cheek and measures 2 × 2 cm. The second ulcer presents on the right lower eye lid and measures 1 × 1.5 cm. The third ulcer presents on the forehead and measures 0.5 × .5 cm (figure ). The examination also revealed no lymphadenphathy or hepatosplenomegaly.\nOn first look to the face of our case, it was difficult to recognize the facial features of Down syndrome because of severe disfigurement of the face, the ulcers were surrounded by extensive edema that caused the eyes to be closed most of the times so the upslanting palpebral fissures which is a very characteristic feature of Down syndrome was not so obvious, in addition the presence of an ulcer near the nasal bridge added more difficulty to recognize the facial features but the presence of hypotonia, flat occiput, short neck, low set ears, short broad hands; clinodactyly of fifth finger; bilateral simian creases of the hands and gap between the first and second toes, directed us to request karyotyping. The result of karyotyping confirmed our suspicion and the diagnosis of Down syndrome was confirmed.\nBlood count and immunological study were normal except for the presence of lymphopenia and inverted CD4/CD8 ratio. The baseline erythrocyte sedimentation rate was normal. Liver, kidney, and thyroid function tests (TSH, T3, and T4) were within normal limits. Histopathologic examination of the ulcers' sections stained with hematoxylin and eosin showed a superficial reticular dermis occupied by large pale histiocytes with leishmania. With the Giemsa stain technique multiple leishmania were seen confirming the diagnosis of cutaneous leishmaniasis. After the diagnosis of leishmaniasis, sodium antimony gluconat was administered intravenously along with other antibiotics, the condition started to improve but unfortunately after two weeks of treatment the child was discharged from the hospital under the request and insistence of his parents. The parents were seeking cautery treatment for the ulcers which is a common practice in the Kingdom of Saudi Arabia; the parents refused all medical advices to continue the treatment in the hospital. The child was discharged and was never seen again.
A 62-year-old male with a past medical history notable for bipolar I disorder, nephrogenic diabetes insipidus, and metastatic colorectal cancer presented with a chief complaint of nonradiating suprapubic abdominal pain. He had no associated emesis or nausea. He did not note any worsening of his symptoms with oral intake of food. He stated that he was last able to urinate 24 hours prior to presentation. Prior to this, he denied any sexual contacts in the past year and denied urinary frequency out of his baseline. He reported no penile discharge. While he did not have fevers, he did endorse chills and night sweats. He denied any recent acetaminophen use. His abdominal pain continued to worsen over the past 24 hours prompting his presentation to our institution's emergency department.\nHis past medical history was notable for bipolar I disorder which was previously controlled with lithium for over 30 years but complicated by the subsequent development of nephrogenic diabetes insipidus. He was initially started on lamotrigine 150 mg in the morning 1 year ago and then transitioned to olanzapine 10 mg in the morning 3 months prior to presentation. His medical history is also notable for prior diagnoses of stage IV colorectal cancer, stage 3 chronic kidney disease (CKD stage III), hypertension, and dyslipidemia. His stage IV colorectal cancer was diagnosed approximately a year and a half prior to this admission. He underwent three cycles of palliative chemotherapy with folinic acid, fluorouracil and oxaliplatin, also known as FOLFOX. Treatment was complicated by the development of bacterial colitis and sepsis requiring laparotomy and segmental resection of the colon. He was able to later restart FOLFOX and received 6 additional cycles as well as palliative chemotherapy; however, follow-up computed tomography (CT) and carcinoembryonic antigen levels revealed progression of his metastatic disease and the patient elected to stop further interventions.\nSurgical history was notable for hemicolectomy approximately 18 months ago as mentioned above as well as an appendectomy as a teenager. Medications on admission included amlodipine 10 mg daily, losartan 25 mg daily, lovastatin 20 mg daily, lamotrigine 150 mg in the morning, and olanzapine 10 mg in the morning. He denied any drug allergies. Socially, he denied ever smoking tobacco or illicit drugs. He did admit to social alcohol use. He is currently divorced and lives with his son.\nOn examination, initial vital signs revealed a blood pressure of 154 over 66 mmHg, heart rate of 132 beats per minute, respiratory rate of 16 breaths per minute, normal oxygen saturation of 97% on room air, and a temperature of 97.6 degrees Fahrenheit. He appeared in mild distress. He made appropriate eye contact and was conversing in full sentences. Cardiac exam revealed normal S1 and S2 heart sounds without S3 or S4. He had no appreciable murmurs. Pulmonary examination was unremarkable. Abdominal exam was notable for central suprapubic tenderness with a palpable bladder. No costovertebral angle tenderness. No overlying rashes revealed on exposed skin. Neurologic exam revealed no hyporeflexia of the patellar or Achilles reflexes, no muscle rigidity, or dystonia. Psychological exam revealed no excessive talking or pressured speech. He did not appear anxious or irritable. No evidence of akathisia or tardive dyskinesia.
An 80-year-old man was admitted to our hospital for the treatment of a rectal tumor found incidentally by rectal examination. The tumor, about 3 cm in diameter, was located on the right side of the lower rectum 3 cm above the anal verge. The pathological analysis of the biopsy sample revealed that the tumor was a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) indicated that the rectal cancer invaded into the muscularis propria without distant metastases and that lateral pelvic lymph node (LPLN) was not enlarged with a maximum long-axis diameter <3 mm. The most important problem was that the patient had a huge benign prostatic hypertrophy, the size of which was 85 × 80 × 70 mm (Fig. a–c). To achieve complete TME with negative CRM, a hybrid transabdominal-transanal approach for ISR was conducted.\nFirst, vascular division and mobilization of the left colon were performed laparoscopically. The transabdominal approach was continued until the anterior dissection of the rectum became difficult due to a huge prostatic hypertrophy. Next, the circumferential rectal incision and subsequent intersphincteric dissection were performed under direct vision to enable attachment of a single port device (GelPoint Mini; Applied Medical). After closure of the anal orifice, the GelPoint Mini was placed to start the transanal approach. Posterior side of the rectum was first dissected until the transanal approach was connected to the dissection layer made by the transabdominal approach. The dissection procedure was extended to the lateral side. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o’clock positions. At the anterior side, the proper dissection layer cannot be easily identified because of the perineal body and the enlarged prostate. Once the dissection plane between the rectum and the prostate could be identified, it was relatively easy to continue along the same plane. The assistance provided by the laparoscopic approach was useful to determine the appropriate dissection line in the transanal approach.
The patient, an 18 years old Caucasian boy, is the second child of consanguineous parents (second degree cousins). His medical history was unremarkable until the age of 7 years, when he developed progressive gait, running disturbances and difficulties in playing soccer. At the age of 9.7 years, he experienced a severe ketotic, hypoglycemic attack. At the age of 10 years, due to the progressive worsening of the neurological symptoms, he was referred to the Unit of Neurology of the University of Messina, where a complex picture of upper and lower motor neuron involvement was recognized. Magnetic resonance imaging of the brain and cervical spinal cord was normal. On that occasion, the presence of marked skin pigmentation and brown spots of the tongue, together with a clinical history positive for ketotic hypoglycemia, suggested the diagnosis of adrenal insufficiency. This clinical suspicion was confirmed by a typical hormonal profile with very high ACTH levels and undetectable levels of cortisol, both basal and stimulated by i.v. ACTH. Further investigations showed an autonomic dysfunction with postural hypotension and abnormal heart reflexes. The oral treatment with hydrocortisone, at substitutive doses (10 mg/m2/day), caused a significant improvement of the patient’s general well being, although ACTH levels remained elevated. The coexistence of ACTH-resistant adrenal insufficiency and neurological manifestations suggested the hypothesis of triple A syndrome, that was confirmed by DNA analysis of the AAAS gene. In fact, sequencing the coding regions and exon/intron junctions of this gene identified a homozygous splice mutation in intron 14. This is a G > A replacement at the first nucleotide in intron 14, resulting in aberrant splicing (IVS14 + 1G > A). As expected, the parents were both heterozygous carriers of the mutation, as well as the two clinically healthy siblings [].\nDuring the clinical assessment, an ophthalmologic exam was performed, because the patient referred of symptoms characterized by foreign body sensation and itching, starting in the morning and worsening in the evening, mild dryness and light sensitivity. Before the clinical exam, an informed consent was obtained. The clinical procedures were in accordance with the Declaration of Helsinki.\nThe ophthalmologic exam included visual acuity assessment, ocular surface study, tonometry, and fundus examination. For the ocular surface study, the following tests were performed: tear osmolarity measurement (TearLab™ Osmolarity System Inc., TearLab™ Corp., San Diego, CA, USA), slit-lamp examination of the ocular surface, tear film break-up time (BUT), corneal fluorescein staining, Schirmer’s I test (SNO strips, Laboratoire Chauvin, Aubenas, France), lid margin assessment, corneal sensitivity, in vivo corneal confocal microscopy (Confoscan 4, Nidek, Vigonza PD, Italy) and conjunctival impression cytology (Supor 200 membrane filters, Gelman Sciences, Ann Arbor, MI, USA) [, ].\nThe best-corrected visual acuity was 20/20 in both eyes. Tear osmolarity was 300 mOsm/l in the right eye (RE) and 332 mOsm/l in the left eye (LE). The slit-lamp examination showed an unstable tear film with a BUT of 2 sec in both eyes. A mild conjunctival fluorescein staining was present in the LE conjunctiva in both interpalpebral areas; no signs of epithelial damage were present in the RE. A mild papillary hypertrophy was present in the upper tarsal conjunctiva in both eyes. Schirmer’s I test was 0 mm/5’ in both eyes. The lid margins showed a mild hyperemia, with meibomian gland expression giving rise to slightly turbid meibum. The keratoaesthesiometry was within normal values (RE = 1.08 g/mm2; LE = 0.96 g/mm2). In both eyes, the corneal confocal microscopy showed normal epithelial features. The subbasal corneal nerves presented a rectilinear course, with occasional beadings (Figure A). Stromal keratocytes, either in the anterior (Figure B) or in the posterior stroma (Figure C), showed morphological features typical of activated cells. Endothelial cells were normal (Figure D). The conjunctival impression cytology showed in RE the presence of islands of bilayered epithelial cells, together with areas of isolated cells. The cells within the bilayered tissue appeared of normal size, with N/C of 1:1 or 1:2. Also the isolated cells showed a normal N/C, although cells with reduced N/C could be seldom observed. Nuclear chromatin showed a condensed appearance. Goblet cells were normally represented. A mild keratinisation was present in some cells (Figure A). The LE showed the presence of islands of bilayered cells, together with areas of isolated and highly keratinized cells with a metaplasic appearance and pyknotic nuclei. Particularly in the isolated cells, the N/C was reduced (Figure B). In the multilayered areas some goblet cells were observed. The intraocular pressure was 14 mmHg in both eyes. The fundus exam was normal in both eyes.
A 65-year-old male was presented with his persistent back pain and daily pyrexia. He had suffered from chronic dyspnea on effort as a symptom of the chronic obstructive pulmonary disease and used home oxygen therapy of 2 l/min on occasional use. He had been followed up for non-small-cell lung cancer (NSCLC) of the left upper lobe (T2aN1M0), which was treated by the SBRT (50 Gy in four fractions) 4 years prior to the current visit. SBRT was effective enough to achieve complete response of the disease, and the patient had developed no evident recurrent disease so far. After the completion of SBRT, he occasionally complained about postprandial soreness in the upper chest for 4 years until the evaluation by the following clinical examinations.\nThe blood examination revealed marked leukocytosis and elevated level of C reactive protein (CRP) (\nTable\n). A computed tomography (CT) revealed thickening of the pleura and the soft tissue adjacent to the left side of the upper thoracic esophagus. The endoscopy revealed an esophageal perforation on its left side in the upper thoracic locus (\nFig.\n). With a diagnosis of the esophageal perforation and mediastinitis, he was referred to our department.\nSince his lung function was quite poor with a vital capacity of 2.31 l and a forced expiratory volume per one second (FEV 1.0) of 0.52 l, a conservative policy was favored. Enterostomy was established by a surgical operation, and he was followed up with a long-term prohibition of oral intake under the enteral nutrition. The inflammatory markers such as leukocyte count and CRP showed improvement, and the patient was discharged to be followed up by the regular surveillance by blood tests and CT.\nAfter 3 months, his back pain recurred with a sudden and steep worsening and he revisited our department on an emergency occasion. The patient developed paraplegia with muscle weakness in the lower extremities. An emergent CT demonstrated a spread of the periesophageal abscess which invaded and destroyed the vertebral body (\nFig.\n). The condition was emergently consulted to an orthopedician. The magnetic resonance imaging (MRI) revealed an abscess formation at the posterior side of the upper thoracic esophagus which penetrated and destroyed the intervertebral disc and vertebral body and compressed the spinal cord at the level of Th2–3 (\nFig.\n). His condition was considered as an indication of emergent surgery for an acute spinal cord injury, and the laminectomy of the Th2–3 and debridement of the malgranulation were performed (\nFig.\n).\nCitrobacter koseri\nand\nStreptococcus mitis\nwere isolated from the specimen of an epidural abscess. After the surgery, his neurologic symptom had gradually improved.\nThe first of the two-stage operation was performed 8 days after laminectomy: the first stage, nontransthoracic esophagectomy, cervical and transhiatal approach using mediastinoscope and laparoscope, described below (\nFig.\na), and the second stage, esophageal reconstruction.\nIn the first stage, the upper mediastinal manipulation was performed by a cervical approach via a collar incision and with mediastinoscopic guidance. There were firm adhesions between the dorsal side of the esophagus and the anterior vertebral ligament presumably caused by the esophagus perforation. After the dissections of the esophagus from the bilateral pleura, dissection of the dorsal side of the esophagus was performed and the perforated site of the upper thoracic esophagus was confirmed in the left-dorsal aspect of the esophageal wall. Subsequently, dissections between the left side wall of the trachea and the esophagus and between the anterior mediastinum and the esophagus were carried out. The left recurrent nerve was sharply dissected from the esophagus and preserved. After these transcervical procedures assisted by the mediastinoscope, the upper thoracic esophagus including the perforated site was free from attachments to the adjacent anatomical structures.\nFollowing to the abovementioned upper mediastinal manipulations, transhiatal approach for the middle and lower mediastinum was performed laparoscopically. Firstly, the anterior side of the esophagophrenic ligament was incised and the mediastinum was entered. The lower esophagus was dissected from the bilateral pleura, the pericardia, and the aorta. As the dissection proceeded to the cranial side beside the esophagus, the dissection was reached to the hollow space surrounding the upper thoracic esophagus which was created by the prior dissections via a cervical approach. Consequently, the whole thoracic esophagus was ready to harvest. After the esophago-gastric junction was transected, the mobilized esophagus was pulled up from the cervical incision. Finally, a cervical esophagostomy was placed in the left side of his neck and a 19-Fr drainage tube was inserted via the left side of his neck into the upper mediastinum (Fig.\nb).\nIn the second stage, surgery for reconstruction was performed 4 weeks after the first stage surgery (Fig.\nc). In the reconstruction surgery, gastric conduit was created with linear staplers via upper median laparotomy. The conduit was lifted via a subcutaneous route, and an esophago-gastric hand-sewn anastomosis (a single layer of Gambee sutures) was performed.\nAlthough left recurrent nerve palsy and anastomotic stricture occurred, the patient’s condition gradually improved with conservative treatment (swallowing rehabilitation and endoscopic bougienage) and he was discharged from hospital at 183 days after esophagectomy. His follow-up was discontinued 12 months after the discharge because of the acute myeloid leukemia which was cared by the best supportive care. By the time, he had been free from any signs of local recurrence or neurological impairments and able to take meals enough to abandon the enteral nutrition.\nSurgical resection is regarded as a standard treatment for early NSCLC while radiotherapy has been offered to patients who are not suitable for surgery due to medically inoperable factors such as poor pulmonary function or severe cardiovascular dysfunction []. SBRT is currently defined as a technique for delivering external beam radiotherapy with a high degree of accuracy to an extra-cranial target, using high doses per fraction, and now considered as the first-line treatment option for medically inoperable patients affected by early NSCLC []. For peripheral lung tumors, low treatment-related toxicity rates have been confirmed in prospective trials, as these tumors are mainly surrounded by lung tissue []. On the other hand, SBRT for central located tumors (< 2 cm from the main bronchus) has a potential risk of developing severe, potentially life-threatening toxicities because of the proximity of the target field to critical organs such as the main bronchus, the esophagus, and the heart []. When SBRT is employed to treat centrally located NSCLCs, the esophagus is typically one of the most crucial organs at risk owing to its close proximity to the radiation field. The adverse effects on the esophagus are well-known complications of SBRT for centrally located lung tumors. These esophageal complications range from esophagitis to esophagus ulcer resulting in stricture, perforation, and/or tracheo-esophageal fistula, and the frequency of grade 1–2 and over grade 3 toxicity according to the Common Terminology Criteria for Adverse Events has been reported as up to 12.8% and up to 6.8%, respectively []. Late esophagus toxicities as defined to occur more than 90 days are usually emerging 3 and 18 months after the termination of radiotherapy []. Sainathan et al. reported two cases of delayed esophageal perforation after SBRT for locally recurrent NSCLC []. In these two cases, esophageal perforation occurred 5 and 7 months after SBRT for centrally located recurrent tumors. As for the case in this report, the first presentation of the esophageal fistula was 4 years after the SBRT and target NSCLC was located in the left pulmonary apex (more than 2 cm distant from the main bronchus). Moreover, to our knowledge, this is the first case report of SBRT-induced esophageal perforation form periesophageal abscess, and this abscess invaded the vertebral body through the intervertebral disc and developed paraplegia.\nSeveral managements for esophageal perforation have been reported such as conservative treatment, esophagectomy, endoscopic clipping, and endoscopic placement of stent [, ] as two cases were treated by a covered esophageal stent []. In the current case, esophageal perforation occurred in the irradiated esophagus, which might be too friable and vulnerable to tolerate the placement of metal stent. There are several case reports that a covered self-expandable and retrievable stent (HANAROSTENT) was effective and successfully manage the esophago-gastric anastomosis fistula [, ]. Although HANAROSTENT could have been a possible choice in this case, we considered that the separation of the gastrointestinal contents from the severely infected mediastinum would be the most reliable measure to manage this critical vertebral infection. Nonetheless, the patient’s severe pulmonary dysfunction (vital capacity of 2.31 l and FEV 1.0 of 0.52 l) made the transthoracic esophagectomy an unsuitable choice. Therefore, we consider the nontransthoracic esophagectomy and delayed reconstruction as a necessary and adequate procedure for this complicated esophageal perforation. The upper mediastinal anatomical structures adjacent to the esophagus may be susceptible to surgical injuries owing to the previous radiotherapy, periesophageal abscess formation, and adhesive changes. Therefore, conventional transhiatal esophagectomy would not be a suitable choice because it includes blind and blunt dissections. The use of mediastinoscope was advantageous to confirm the surgical view directly and prevented secondary injuries on the anatomical structures adjacent to the esophagus.
(1) A healthy 87-year-old man presented with a three-month history of spontaneous, clear, left-sided ND. There was a significant family history of breast cancer as a maternal aunt, and two sisters were diagnosed in their early 60's. On examination, he had a firm, 2 cm mass in the upper outer quadrant of the left breast. There was no skin ulceration or tethering, no nipple retraction, and there were no enlarged axillary lymph nodes. The discharge came from the centre of the nipple, and, clinically, it was not possible to say if this was uniductal. The discharge was sent for cytology, and a core biopsy of the mass was also performed. ND cytology was inconclusive with no evidence of any epithelial cells, but core biopsy of the lump revealed the presence of invasive adenocarcinoma.\nAfter counselling, the patient went on to have a mastectomy and axillary sentinel lymph node biopsy (SLNB). Histology showed a grade 2 invasive papillary carcinoma 19 mm in maximum dimension, with clear margins. No lymphovascular invasion was seen, and the one SLNB was negative for metastatic tumour. Immunohistochemistry demonstrated the tumour was strongly oestrogen receptor (ER) positive without HER2 over amplification. The patient made a good postoperative recovery and had adjuvant endocrine treatment with tamoxifen. Due to his strong family history, he was offered genetic counselling but he refused and remained well 2 years postoperatively.\n(2) A 77-year-old gentleman presented with bloody ND and a lump in the left breast for 6 weeks. There was no history of trauma and no family history of note. On examination, there was a cord-like mass beneath the areola extending into the upper outer quadrant of the left breast, with no skin or nipple abnormality. The patient underwent a mammogram and ultrasound scan both of which were highly suggestive that the mass was malignant. The ND cytology revealed atypical epithelial cells. Core biopsy of the mass revealed the presence of invasive adenocarcinoma. The patient was treated with mastectomy and SLNB. Histology revealed a grade 2 invasive ductal carcinoma with clear margins and no lymphovascular invasion present. A single node was retrieved at SLNB which was negative for metastatic carcinoma. Immunohistochemistry showed the tumour was ER positive. He was prescribed adjuvant tamoxifen and remained well 4 years postoperatively.
A 58-year-old female presented to the emergency department with intermittent, crampy right-sided abdominal pain, nausea, and vomiting, which began approximately 18 hours previously. Her past medical history was significant for hypertension and her surgical history included a thyroidectomy for treatment of thyroid cancer and a Caesarean section. A contrast enhanced CT abdomen and pelvis was obtained, demonstrating multiple fluid-filled, dilated small bowel loops in the right abdomen, which were predominantly anterolateral to the ascending colon and cecum (). In addition, two transition points were identified in the right lower quadrant, with one transition point at the distal ileum just proximal to the cecum and a second transition point in the proximal ileum. The two transition points were in close proximity to each other, indicative of closed loop obstruction. Decreased wall enhancement of the dilated small bowel loops was concerning for ischemia. Mucosal hyperenhancement of the ileum at the proximal transition point was felt to relate to ischemia or decompressed state (). Given the patient's symptoms and findings of closed loop obstruction on CT, the patient was taken to operating room. In the operating room, an internal hernia with closed loop obstruction was confirmed and resulted from herniation of small bowel through an adhesion of a transverse colon epiploic appendage to the ascending colon mesentery. The herniated small bowel was nonviable and a total of 60 cm of small bowel was resected (). Retrospectively, kinking of the ascending and transverse colon could be seen on the initial abdominal CT and was felt to correspond with the site of adhesion ().\nAfter resection, the patient's small bowel was left in discontinuity and an abdominal wound-vac was placed. The following day, the patient returned to the operating room, at which time the terminal ileum was also found to be nonviable. An ileocecectomy with enterocolonic anastomosis was performed.\nThe patient had a complicated postoperative course, but was ultimately discharged approximately two weeks after the initial surgery.
A 40-year-old man was admitted to the emergency department due to severe chest pain. He complained of persistent tightness in the left anterior chest. An emergent coronary angiogram (CAG) revealed total occlusion of the proximal left anterior descending coronary artery (LAD). Percutaneous coronary intervention with stent implantation in the LAD successfully restored coronary blood flow and completely relieved his chest pain (). Five days later, the patient began to complain of left anterior chest discomfort, which gradually worsened over the next two weeks. Although the cardiologists again performed a detailed evaluation of cardiac function, there were no changes in the electrocardiogram and cardiac enzymes and no in-stent restenosis or de novo lesions seen on the CAG. Over the next year, the patient visited the emergency department and admitted several times due to his relentless chest pain, thus the total days of hospitalization was about half a year. Multiple cardiac evaluations were performed to elucidate the cause of the angina. Another stent was implanted in the obtuse marginal branch of the left circumflex artery for intermediate stenosis. Ergonovine-induced spasm in the right coronary artery was detected on another angiography, and the cardiologists added a calcium channel blocker to the patient's medications. However, these additional interventions did not improve his symptoms. Adequate results could not be obtained on an exercise electrocardiogram, due to the patient's poor exercise tolerance. Echocardiography showed persistent ischemic cardiomyopathy with moderate left ventricular dysfunction. A follow-up coronary angiogram showed patent previously stented arteries and no significant stenosis in other arteries.\nWhen the patient was referred to the pain clinic, he was experiencing paroxysmal deep anterior chest pain 2 or 3 times a day. The pain was of a squeezing and pressing nature, 7 to 8 on a numeric rating scale (NRS, 0 = no pain, 10 = maximum pain), and was not relieved by sublingual nitroglycerine. For several months, while the patient was prescribed oral morphine 90 mg, gabapentin 1,800 mg, and nortriptyline 20 mg per day, we tried various procedures to control his pain, such as stellate ganglion block, percutaneous thoracic sympathetic neurotomy using thermal radiofrequency, epidural morphine injection, and intravenous ketamine infusion. These techniques all had only temporary efficacy. Finally, despite a continuous epidural infusion of morphine, his paroxysmal angina was worsening, rising to 8 to 9 on the NRS.\nAfter careful discussion with the patient and his family, they agreed to a trial of SCS. The patient was taken to the operating room, monitored, and placed in the prone position. Anesthesia was accomplished by local anesthetic infiltration. A 15-gauge Tuohy needle was inserted in the T4-5 interlaminar space under fluoroscopic guidance. The epidural space was identified using a loss-of-resistance technique. An Octad lead 3778 (Medtronic Inc., Minneapolis, Minnesota, USA) was inserted through the needle and advanced under fluoroscopic guidance until the tip lay at the C7-T1 intervertebral disc level (). The stimulation parameters were pulse width of 270 µs, amplitude of 2.0 mA, and frequency of 50 Hz. During the 10 days of trial stimulation, the intensity and frequency of the patient's chest pain was reduced by 60-70% without epidural infusion of morphine. Therefore, a permanent pulse generator (RestoreUltra™, Medtronic Inc., Minneapolis, Minnesota, USA) was implanted into the subcutaneous space of the right lower quadrant of the abdomen. The patient's chest pain decreased to 2 to 3 on the NRS, and he was satisfied with a treatment regimen of SCS and oral morphine 90 mg, gabapentin 1,800 mg, and nortriptyline 20 mg per day. Although the doses of medication did not decrease, the improvement in the patient's clinical symptoms persisted at the follow-up evaluation performed 1 year after surgery.
We present a case of a 64-year-old Caucasian male with a medical history considerable for chronic obstructive pulmonary disease and traumatic brain injury presented with worsening right inguinal area swelling for the past 5 years. The patient was asymptomatic otherwise. A computed tomography (CT) scan of the abdomen and pelvis was obtained first time in 2015, which demonstrated pelvic and abdominal lymphadenopathy. He was referred to surgery for an excisional biopsy, which revealed follicular lymphoma World Health Organization Grade I-II (). Fluorescence in situ hybridization (FISH) was positive for IGH/BCL2 translocation t(14;18)(q32;q21). It was negative for MYC/IGH translocation and BCL6 rearrangement. It was determined at the time of diagnosis that the optimal therapy would be observation. One year later, the patient complained of generalized weakness as well as difficulty urinating due to obstructive uropathy secondary to lymph nodes that were identified on a CT scan of the abdomen and pelvis. Bone marrow biopsy was performed at that time and was positive for follicular lymphoma involving bone marrow (). Morphology and flow cytometry were positive for 20% involvement by follicular lymphoma cells. Flow cytometry showed a large population of CD19-positive cells that co-express CD10. Neoplastic lymphocytes were positive for CD20 and expressed a kappa surface light chain in a restricted fashion. The FISH was positive for IGH/BCL2 translocation. After a discussion with the patient, he was given 4 weekly doses of rituximab in 2016, with subsequent CT scans showing an almost 40% reduction in the size of the lymph nodes involved. Given some response and resolved obstructive uropathy, the patient was again placed under active surveillance with laboratory results and serial imaging to monitor for any relapse. He also had comorbidities and it was decided to hold off on any systemic treatment. During that period, the patient’s case was further complicated by an upper extremity deep vein thrombosis requiring oral anticoagulation as well as a lower extremity fracture requiring surgical repair. He also developed multiple squamous cell carcinomas (SCCs) of the face treated with local excision around 6 months after completion of rituximab therapy. There were no cell count abnormalities, B-symptoms, or radiological evidence of disease progression.\nTwo years after the patient received rituximab, he underwent Mohs microscopic surgery to remove a lesion on the right side of the face. The biopsy contained evidence of both SCC and follicular lymphoma (CD20+, CD10+ with BCL2 rearrangement by FISH) and no evidence of large cell transformation. Positron emission tomography (PET)/CT was done in November 2018, which was compared with PET/CT done in September 2016 before first treatment. It showed the abdominal lymph nodes with some response from prior therapy, findings were still consistent with improvement compared with prior scans; however, on current PET/CT scan, there was new abnormal uptake on the left side of the scalp and soft tissue density along with the anterior right submandibular gland. There was uptake along left lateral scalp where there is scalp thickening measuring 10 mm with maximal SUV of 8.3. There was soft tissue density along anterior right submandibular gland which measured 1.5 × 1.9 cm and there was maximum SUV of 6.0. There was hypermetabolic activity within retroperitoneum with maximum SUV 10. This measured 2.4 × 3.0 cm and was previously larger and there was more extensive involvement. There were hypermetabolic lymph nodes in right common femoral region. Lymph node had maximum SUV 11.6 and the largest lymph node measured 1.9 × 1.6 cm. Previously there was more extensive lymphadenopathy in this location.\nGiven the new relapse involving extranodal sites, the patient was offered systemic therapy with rituximab and bendamustine. He ultimately refused chemotherapy and was treated again with 4 cycles of rituximab in January 2019. Interval PET/CT in April 2019, 8 weeks after therapy suggested complete response to treatment with resolved abdominal lymphadenopathy as well as improvement in the lesion of the right side of the patient’s scalp. As compared with previous PET/CT in November 2018, paraortic and bilateral iliac lymphadenopathy had resolved. There was no abnormal hypermetabolic focus in abdomen and pelvis and no abnormal hypermetabolic activity was seen in the neck.\nThree months later, he again developed swelling on the left side of his face (). A biopsy was obtained and found positive for low-grade follicular lymphoma, Grade I-II (). FISH was positive for translocation t(14;18)(q32;q21)/IGH-BCL2 rearrangement, consistent with the relapse. The patient was referred to radiation oncology for palliative radiation as he was initially refusing chemotherapy. Another PET/CT scan demonstrated skin thickening in the facial area, neck, scalp, and upper thorax with no evidence of disease elsewhere (). Given the extent of illness, he was not deemed an appropriate candidate for radiation therapy. Accordingly, he agreed to be treated chemo-immunotherapy. The patient was started on bendumastine and rituximab. He had a good clinical response with improvement in his skin lesions.
A previously healthy male in his 30s presented to the emergency department with a 2-day history of pain and swelling in his right upper extremity after striking a heavy bag with an uppercut punch. At the time of event, the patient felt a sudden sharp pain radiating from the wrist to the elbow, which eventually localized to the elbow. Over the next 2 days, the patient gradually developed swelling and diffuse erythema from the proximal aspect of the right arm to the wrist, tension, and decreased elbow, wrist and finger mobility. He reported a history of compartment syndrome requiring fasciotomy in his right distal arm and proximal forearm due to an automobile accident-induced crush injury 10 years prior. On exam, he was tender to palpation, weak to grip, but had intact sensation and vasculature. Initially, cellulitis was suspected, partly because of the appearance of his extremity and an unlikely traumatic mechanism for ACS. Radiographs were unremarkable for fractures. Magnetic resonance imaging (MRI) revealed extensive edema in the proximal brachioradialis muscle and extensor carpi radialis longus muscle, as well as increased signal in the extensor musculature at the dorsal aspect of the arm, but no fracture or tendinous, ligamentous or muscular tear (Fig. ). Ultrasound showed a non-occlusive thrombus in the right axillary and brachial veins, for which the patient was eventually started on anticoagulation. All initial labs were unremarkable except the CPK of 973 and the patient was subsequently admitted.\nOn hospital Day 4, due to lack of improvement on antibiotics, worsening of pain and growing suspicion for ACS, the patient was taken to the operating room (OR). After dissection of the fascia, it was found that the muscles of the mobile wad had a dark and dusky appearance along with an associated hematoma, consistent with the diagnosis of ACS. The hematoma was evacuated and vacuum assisted closure of the wound was performed (wound VAC). Four days later, the wound was re-examined in the OR, and the muscles looked pink without signs of necrosis. The wound VAC was removed and the incision was primarily closed. During his stay, the patient developed acute renal failure presumed to be due to rhabdomyolysis-induced myoglobinuria. The renal failure subsequently resolved and the patient was discharged home with no residual symptoms.
A 43-year-old multiparous female, G3P3, normal vaginal delivery, presented to our hospital with complaints of abdominal distension and abdominal pain with pelvic heaviness. There were no disturbances in the bladder and bowel function. There were no associated other symptoms. She was on an intrauterine device as a contraceptive method. General physical examination was free. Her vitals were free. Her abdomen was distended with a huge pelvi-abdominal mass of a pregnancy size of 20 weeks. The mass was nontender and firm. It has limited mobility from side to side. Pelvic examination revealed normal vulva and vagina. The cervix was drawn up and deviated to the left side. It was closed and grossly looking healthy. Abdominal ultrasound showed a huge solid mass measuring 20 cm beside the right side of the uterus. Her full blood count and serum biochemistry were within normal limits. Computed tomography (CT) scan and intravenous urography were not done because of patient's financial constraint. A diagnosis of broad ligament leiomyoma was suggested. She was scheduled for hysterectomy. Intraoperatively, following a low transverse large incision, a huge right broad ligament leiomyoma measuring approximately 20 cm in its widest diameter was seen. The uterus was pushed up and displaced to the left side. The mass was extending deep in the pelvis to the level of the ischial spine, occupying the pelvis with difficult delivering the uterus from the incision for hysterectomy. The round ligament stretched over the mass was incised by diathermy and extending the incision down to the capsule of the mass. The plane of cleavage was identified, and the mass was enucleated gently following the capsule taking care at the bed of the myoma avoiding injury to the ureter. Maintaining dissection of the myoma intracapsular, close to the myoma and avoiding pulling it out sharply preventing injury to the ureter. The mass was separable easily from the uterus with no blood supply from it, and it was mainly from pelvic vessels. Then, total hysterectomy with bilateral salpingo-oophorectomy was done. The bed of the myoma was oozing so, bilateral internal iliac artery ligation was done securing hemostasis [Figures and ]. The mass was sent for histopathology and was confirmed to be a fibroid. The patient discharged to home after 2 days.
A 12-year-old female child from Indian Gangetic belt presented with complaints of fever and pain in right thigh since 3 weeks. Fever which responded to antipyretics was of moderate degree with documentation not more than 101°F. The febrile episode was intermittent with no diurnal variation or associated chills and rigors. Two days after the onset of fever, the patient had reported pain and swelling in right distal thigh, with restricted movement of right knee due to pain. Patient had complaints of generalized myalgia in the initial week of fever. On further direct questioning, the patient gave a history of patchy red rash over the front and medial aspects of thigh on the 2nd day that lasted for around 6–8 hours. There was neither a history of trauma or photosensitivity nor any symptomatology localizing to respiratory, urinary or central nervous system. Further probing confirmed absence of any antibiotic treatment for fever till the time of admission. The patient hailed from a low socioeconomic background, was a non-vegetarian and occasionally used to consume pork. The patient had consumed hamburger in the past 1 month, following which she had an episode of diarrhea, dyspepsia and myalgia for 4 days. But the episode was self-limiting and the patient improved on her own without taking any medications. However, none of the relatives of the patient or any other person in the region had reported similar complaints.\nOn examination, tenderness in the right thigh reaching up to the knee joint with a mild local rise in temperature was found. Knee movements were painful and restricted. Palpation of inguinal lymph nodes revealed lymphadenopathy. However, systemic examination including examination of other joints was found to be within normal limits.\nX-rays of the right femur revealed grossly normal bony architecture but altered soft tissue shadows in the surrounding thigh musculature []. Laboratory investigations revealed an elevated WBC count (13,700/mm3) with eosinophilia of 10%. However, blood cultures were found to be sterile. A finding of eosinophilia led us to investigate for the serological markers of various parasitic infections. The serology tests were found to be positive for IgM antibodies to Trichinella species. Trichinella spiralis was suspected since it is the predominant Trichinella species in the region.[] An ultrasound done at the same time revealed bulky and heterogeneous deep muscles of the posterolateral aspect of mid and lower thigh with a multiloculated fluid collection suggestive of myositis. This was followed by an MRI [] that was done 2 weeks later which highlighted signs of acute osteomyelitis of lower end of femur with large collection of abscess in deep posterolateral aspect of thigh along with infiltration of adjacent muscles.\nA serous discharge was obtained on needle aspiration, which on microscopy showed occasional pus cells; however, gram stain, acid-fast bacilli (AFB) and culture sensitivity were found to be negative. Nevertheless, a provisional diagnosis of acute osteomyelitis was kept and the patient was taken up for debridement and corticotomy. Intraoperatively, the muscles appeared to be edematous, bulky and unhealthy with minimal seropurulent discharge. Serous discharge amidst marrow fat was expressed on corticotomy. The entire area was drained and tissue specimens were harvested intraoperatively for histological and microbial evaluation. A detailed microbial workup revealed findings summarised in :\nHistopathologic examination of muscle biopsy revealed parasitic infection with esosinophilic infiltrates, and a possibility of parasitic cyst was kept on the basis of histological findings [Figures –]. Considering the isolation of Trichinella larvae as reported by the pepsin digest muscle biopsy study and a histological and laboratory picture suggestive of parasitic infestation, a diagnosis of Trichinella predisposing to bacterial pyomyositis was made. Considering the high prevalence of staphylococcal pyomyositis and osteomyelitis, the patient received 4 weeks of empirical intravenous cloxacillin along with ceftriaxone following surgical drainage and debridement. This was followed by additional 2 weeks of oral cephalosporins. Oral mebendazole in a divided total dosage of 600 mg per day was given for a period of 14 days to cover for the Trichinella infection. The patient's general condition improved and fever subsided gradually over 1 week. Early range of motion at knee and mobilization with full weight bearing was initiated immediately after the surgery. Follow-up after 6 months showed the patient to be disease free with no complaints in playing or carrying out her day-to-day activities.
A 55-year-old Caucasian man was admitted for a left-sided metal-on-metal primary hip arthroplasty for osteoarthritis. There was nothing significant in his medical history and he was a non-smoker with a body mass index (BMI) of 38. The patient experienced no significant intra-operative complications but required four units of blood immediately after his operation, which was attributed to intra-operative bleeding.\nOn the first postoperative day, the patient's hemoglobin level was 65 gm/l. He was subsequently transfused with three units of blood. His low hemoglobin levels were again attributed to intra-operative bleeding. On the second postoperative day, the patient complained of intermittent pain in his left thigh that was associated with numbness and tingling in his toes. His thigh was swollen, but the incision site was dry and there was no pulsatile mass. He remained hemodynamically stable and had distal pulses. His hemoglobin was still only 70 gm/l despite him being transfused with seven units of blood. His clotting profile was also normal. It was thought that the patient had a hematoma which could be was responsible for the pain, the altered sensation, the swelling, and the drop in hemoglobin. The patient was transfused with two more units of blood and four units of fresh frozen plasma. On the third postoperative day, since the patient's hemoglobin remained low despite repeated transfusions, an emergency angiogram was performed.\nThe angiogram revealed an injury that was distal to the left common femoral artery (Figure ). The profunda femoral artery was noted to be normal. The vessel was not suitable for embolisation due to its close proximity to the common femoral artery bifurcation. The patient therefore underwent an open exploration of his left groin. An avulsion injury to a posterior perforating branch of the profunda femoral artery was identified and ligated. A left psoas hematoma and a hematoma in the deep tissue of the upper thigh were also drained. The patient recovered well after the second operation and was discharged 12 days after his initial surgery.
A 75-year-old woman with no significant medical history presented with abdominal pain for one week. She was tender in the left costovertebral angle and had frequent voiding symptoms without gastrointestinal problems. Routine urinary analysis showed many red blood cells and 20-29 white blood cells per high power field of microscopy indicating renal stone disease. Other laboratory tests were unremarkable. Chest computed tomography (CT) was performed for evaluation of a nodular lesion in the right lower lung field that was detected on routine chest radiography leading to the incidental discovery of a low-density lesion in the left hepatic lobe. While she was admitted to the hospital for treatment of left renal stone disease, further evaluation of the incidental low-density lesion in the left hepatic lobe was performed. Ultrasonography (US) of the upper abdomen demonstrated a 3.1 cm-sized mixed-echoic nodular lesion in segment IV with a hyperechoic rim (). The right portion of the lesion was anechoic (solid arrow) while the left was hyperechoic. An abdominal CT scan revealed a lobulated mass with a cystic component in the right portion of the mass and delayed enhancement in the left which was thought indicate solid component (). Magnetic resonance imaging (MRI) of the liver was performed for further evaluation of the mass. The right side of the mass was seen as low signal intensity while the left side was enhanced on gadolinium-enhanced T1-weighted image (), thus matching to the CT features. However, T2-weighted images showed bright high signal intensity throughout the whole lesion () suggesting that the lesion was composed of aggregated cysts rather than solid tissue. For confirmative diagnosis, the patient underwent gun biopsy using US-guidance, the results of which demonstrated microscopic findings of a sponge-like lesion composed of microscopic cysts lined by attenuated cells resembling those in normal lymphatic ducts (). In addition, the lining cells showed staining for the endothelium marker, CD34 (). The final histopathologic diagnosis for the specimen was hepatic lymphangioma.
A 16 year old male student of average built presented to us with progressively increasing swelling in the outer aspect of left ankle for last two years. Patient also gave history of pain off and on. There was no history of difficulty in walking or restriction of movements at ankle. There was a globular swelling measuring 6 cm × 5 cm over lateral aspect of ankle on examination (Fig. and ). It was bony hard in consistency, smooth with ill defined margins and non tender on palpation. There was no distal neurovascular deficit.\nPatient was subjected to anteroposterior, lateral and oblique radiography of leg with ankle. Radiography revealed a well defined bony exostosis, arising from the interosseous border of distal tibial metaphysis with erosion and impending fracture of fibula on oblique view (Fig. &).\nThe patient was initially put in an ankle foot orthosis. The nature and prognosis of the condition was discussed at length with the patient and his family and operative intervention was planned once an informed and written consent was obtained. An MRI scan was ordered once the decision was made to undertake operative intervention. It was consistent with a large, broad based benign osteochondroma arising from the lateral aspect of distal tibia with an uncalcified cartilagenous cap (Fig. ). This led to a marked pressure erosion of the distal fibula, which was only 5 mm thick at the narrowest point (Fig. ).\nThe patient underwent excision of the osteochondroma through an anterior approach without fibular osteotomy. Intra-operatively, the fibula was found to be quite thin and weak. However, its outer cortical shell was intact. The inferior tibio-fibular joint was stable. Histology confirmed the clinical diagnosis of osteochondroma with no malignant transformation. Post-operatively, the patient was mobilised, non-weight bearing in a below knee plaster, for four weeks. Further mobilisation was undertaken with a gradual transition from partial to full weight bearing. At one year follow-up, he had made a complete recovery with full return of ankle functions. The fibula had recovered the full thickness. There was no evidence of recurrence and he is still under follow up.
This professional female soccer player (32 years old, Northern European ethnicity, white) reported episodes of sharp pain in the Achilles tendon for about 2 years. During sudden change of direction and sprinting, she described sudden sharp pain in the midportion of the Achilles tendon; a symptom that initially rapidly settled within minutes, and she could continue to train and play. However, over time, her pain episodes increased in frequency and intensity. After a couple of days of rest, her pain would settle and she was able to return to full training. Eventually, she had to cease training and match play. Clinical examination showed a minimal thickening of the Achilles tendon midportion, with some tenderness localized to the medial and superficial side of the Achilles tendon, suggesting a diagnosis of midportion tendinopathy. Although treatment with eccentric training was trialed, these exercises caused more irritation in the affected region. As the condition failed to settle and the athlete could not properly train and play at desired level, she presented for an assessment at our clinic.\nShe was a non-smoker, did not abuse alcohol, was on no medication, and had no allergies. During initial clinical examination, blood pressure was 120/70 mmHg and resting pulse 60 bpm. Clinical findings were similar as found previously, with minor thickening in the Achilles midportion and tenderness localized to the medial and superficial side. Ultrasound examination showed a normal Achilles tendon measuring 5 mm in the midportion and with normal blood flow. Dynamic ultrasound scanning identified the plantaris tendon proximally. Following the plantaris distally to the region with localized tenderness, a wide and thick plantaris tendon was located on the superficial side of the Achilles midportion (Fig. ).\nThe suspected diagnosis was plantaris tendon-related pain, and the patient was surgically treated with local removal of the plantaris tendon performed under local anesthesia (5 ml Xylocaine + adrenaline) (Fig. ). The procedure took about 30 minutes. During surgery, the thick and wide plantaris tendon was found to be located on the superficial side of the Achilles tendon midportion (Fig. ). Between the tendons, there was a richly vascularized fatty layer that was scraped loose and removed [].\nAfter surgery, there was rest with elevated foot overnight, and pain cure using paracetamol 500 mg, 2 tablets every 6 hours during the first 24 hours, if needed. There was a relatively quick (4–6 weeks) rehabilitation, with immediate weight bearing and range of motion (ROM) exercises, gradual increase in loading according to a specific program, and a return to running activities after 4 weeks. At follow-up at 8 weeks, the patient was in full training, and had not experienced any further episodes of sharp pain during change of direction and sprinting.
A 25-year-old male was brought to our emergency department following a road traffic accident in July 2018. The patient was intubated in view of poor score on Glasgow Coma Scale (GCS). He was hemodynamically stable. On clinical examination, the patient had bilateral decreased air entry and positive chest compression. There were no abdominal signs. On focused assessment with sonography in trauma (FAST) there was minimal free fluid in the abdomen. Contrast-enhanced computed tomography (CECT) of thorax and abdomen showed bilateral hemopneumothorax and a grade III liver laceration. Initial non-contrast computed tomography (NCCT) of brain showed no intracranial injury but later the patient was declared to have a diffuse axonal injury and was shifted to critical care unit for monitoring. The liver laceration was managed conservatively since the patient was hemodynamically stable. Hemopneumothorax was managed with bilateral intercostal drains. The patient’s GCS was persistently poor. Initially, the patient was started on enteral feeds through nasogastric tube and later a PEG tube placement was planned for the purpose of continuing enteral feeds.\nThe procedure was performed while the patient was on endotracheal tube, and under intravenous (IV) sedation. A 20 Fr PEG tube was placed by the standard ‘Pull’ technique. Second look endoscopy confirmed the position of the internal bumper against the anterior wall of the stomach. Externally the tube was fixed and free flow of saline through the PEG was confirmed. There were no complications during the procedure and the patient was started on enteral feeds through the PEG tube on the same day. The patient was extubated after few days but he was continued on PEG feeds as his GCS was persistently poor.\nAt four weeks after PEG there was peritubal leakage noted during feeds with resistance to the flow of feeds initially, which later progressed to complete the blockage. On examination, there was a slight bulge at the site of PEG tube insertion. There was granulation tissue visible sprouting through the tract externally (Figure ). The patient had no signs of peritonitis and the abdomen was soft. On flushing the tube with saline, peritubal leakage was noted and there was resistance to flow. Endoscopic examination was performed to visualize the position of the internal bumper. On endoscopy, the internal bumper was not visualized. Only a small dimple was seen in the mucosa of the anterior wall of the stomach (Figure ). The internal bumper appeared to have migrated through the tract and was entirely covered by the gastric mucosa with only a small dimple seen at the site of the tract. An ultrasound of the abdomen was performed which showed that the internal bumper was in the intramuscular plane of the rectus abdominis muscle (Figure ).\nAs the patient’s GCS was still poor with no mature swallowing reflex, we planned to remove the old PEG tube and replace it with a new one for continued enteral feeding. The procedure was performed under general anaesthesia. Under fluoroscopic guidance, a guide wire was passed through the previous PEG tube from outside piercing the gastric wall. Then the old PEG was removed by gentle firm traction and the tract was dilated using dilator passed over the guide wire. The position of the dilator inside the stomach was confirmed by injecting a contrast dye under fluoroscopic visualization. Since the tract was well formed, a 20 Fr balloon replacement gastrostomy tube was inserted from outside and secured (Figure ). Once again the position was confirmed by fluoroscopy and free flow of saline. The patient was started on PEG feeds later on the same day and had no complications. The patient was followed up for a month and was on continuous PEG feeds without any complications.
An 82-year-old man who lived independently in a retirement village was diagnosed with locally invasive transitional cell carcinoma of the bladder. He had two transurethral resections of his bladder tumor and one treatment of local palliative radiotherapy. He had long-standing excruciating pain over his penis and groin associated with recurrent urinary tract infections. He was a fiercely independent man who was cognitively sound and enjoyed gardening and driving. His wife had died several years earlier and he had a close female companion who was his major support.\nHe had neuropathic pain secondary to the infiltration of the pelvic neural plexus by the invasive transitional cell carcinoma. Morphine was poorly tolerated both orally and subcutaneously due to intractable nausea and vomiting. He also had borderline renal function. He had been prescribed various neuropathic regimes with minimal response. His pain remained uncontrolled on transdermal Fentanyl patch 125 mcg/hr and Gabapentin 900 mg/day. Ketamine and Lignocaine infusions did not improve pain-control.\nHis pain remained largely unchanged and with advice from the tertiary chronic pain management unit a decision was made to use intrathecal analgesia. An epidural catheter was initially inserted as a temporary emergency measure. As recurrent urinary tract infections were an issue, the intrathecal catheter was inserted at the tertiary hospital under appropriate antibiotic cover without an infusaport, delivering Bupivacaine and Fentanyl. The patient had an excellent response reporting total freedom from pain following the procedure.\nFour days later, the dressing around his intrathecal catheter site was completely soaked with cerebro-spinal fluid (CSF). Compression bandages were applied at various sites combined with a large volume intrathecal infusion to prevent CSF leak. Two unsuccessful attempts were made to stop the flow of CSF using an epidural blood patch. The intrathecal catheter was subsequently reinserted with a subcutaneous port. For these procedures he required ambulance transfer to and from the tertiary hospital, taking 60 minutes each direction. This was very distressing for the patient causing pain and extreme fatigue. The patient developed paraparesis following an inadvertent overdose due to a malfunctioning of the intrathecal pump. Prior to this procedure he was ambulant, driving and keeping company with his female companion. He was discharged following the intrathecal procedure with partial paraparesis, an indwelling catheter, and using a wheel chair.\nHe was discharged to his daughter's home. Two weeks later he developed an infection at the infusaport site which required hospitalization and treatment with intravenous antibiotics. He underwent total cystectomy with ileal conduit, which led to complete resolution of his pain and removal of his intrathecal catheter. He had recurrence of his tumor six months later, with increased pain requiring reinsertion of the intrathecal catheter. He had multiple hospital admissions with pain and infections and was placed in a high level care nursing home. He died several months later.
A 66-year-old man with a history of Billroth II gastrectomy for peptic ulcer disease some 35 years ago and an open cholecystectomy some 10 years ago presented to the emergency department with diffuse abdominal pain, vomiting, and diarrhea. The patient admitted receiving nonsteroidal anti-inflammatory drugs and colchicine for persisting gout crisis and diffuse articular pain. He was afebrile and physical examination revealed mild tenderness to deep palpation in all four abdominal quadrants. Rectal examination revealed an enlarged prostate. On laboratory tests there were marked leukocytosis of 48,000/mm3, international normalized ratio (INR) of 2.5, and C-reactive protein of 48 mg/l. Arterial blood gas analysis showed a pH of 7.21, base excess of 13.6 mEq/l, and pCO2of 33 mmHg. At the time of the initial presentation the patient was judged by a surgeon as not having an acute abdominal disease.\nThe plain abdominal X-ray did not show any pathology. An ultrasound showed a simple left renal cyst. A computed tomography scan showed dilatation and edema of the jejunal loops close to the gastrointestinal anastomosis and a minimal quantity of free fluid in the peritoneal space. The radiology report suggested possible localized peritonitis in the proximity of the gastrointestinal anastomosis. Within 2 h of the first surgical examination the patient developed respiratory failure and required intubation and mechanical ventilation. The patient rapidly became severely hypotensive (60/40 mmHg), and oliguric and inotropic support was initiated. Macroscopic hematuria was also noted. At this point the patient received inotropic support. Since the possibility of an intra-abdominal collection was not ruled out on computed tomography scans and no other source of septic shock was identified, an emergency explorative laparotomy was decided on. On laparotomy, no anastomotic leak was found and no other source of abdominal sepsis identified. After laparotomy the patient continued with multiorgan failure and died 16 h after the surgery.\nThe autopsy has not been performed. The diagnosis of colchicine overdose was made postmortem on the basis of the information obtained from other members of the family and is therefore an exclusion diagnosis.
A patient aged 27 years was admitted to Department of Obstetrics and Gynecology, Tanta University Hospitals, in a shock state with a pulse rate of 120 b/m and blood pressure of 80/50.\nThe patient had history of primary infertility for 6 years and history of ovulation induction in the cycle preceding this pregnancy, history of uterine anomaly, and history of amenorrhea for 7 weeks. This means that this pregnancy was induced by ovulation induction.\nImmediate routine investigations included complete blood count and renal and liver functions with bleeding and coagulation times. All investigations were within normal except for hemoglobin which was 9.7 g/dl and hematocrit value of 30.21. Specific investigations requested were pregnancy test and b-HCG level which revealed pregnancy with b-HCG level of 2140 IU. Immediate resuscitation was done by insertion of 2 wide pore cannulas and intravenous fluids with immediate ultrasound which revealed bicornuate uterus and moderate free fluid in the abdomen; pelvic hematoma about 10 × 3 cm was also detected in the pelvis. The uterus was empty and pregnancy sac was found between the two horns of bicornuate uterus with high peripheral vascularity surrounding the sac “Ring of Fire,” .\nTaping of free fluid which revealed altered dark blood confirmed the diagnosis of ectopic pregnancy. The patient did not receive preoperative blood and was immediately transferred to operation room with 2 units of crossmatched blood ready to be used intraoperatively or postoperatively. Laparotomy revealed moderate to severe internal hemorrhage with blood clots in pelvis. Pelvic hematoma was anterior to the bicornuate uterus between uterus and bladder covering pregnancy sac. Both fallopian tubes and ovaries were inspected and were healthy with no lesions denoting that the ectopic pregnancy was primary.\nSuction of blood and clearing retrovesical hematoma revealed pregnancy sac in between the 2 horns of bicornuate uterus which was enucleated and debridement of its site and repair of its bed to control bleeding as shown in .\nClosure of ectopic pregnancy site by Vicryl 2/0 and the end picture were shown in .\nThe abdomen was irrigated by 2 liters of warm saline and closure of abdominal wall was then commenced in anatomical layers. Postoperative follow-up consisted of monitoring vital signs and urine output. The patient was given the 2 units of blood one inside operation room and one after 12 hours. Complete blood count was requested before discharge with hemoglobin 10.8 g/dl. The case was discharged 24 hours after operation in a good condition.
A 55-year-old male presented with a gradually increasing mass on the left lateral lower chest and upper abdomen over a period of one year. He had no other medical problems and no history of contact with a tuberculous patient. On examination, a lobulated subcutaneous mass measuring about 7 cm in diameter, soft to cystic in consistency, immobile and attached to the skin which was tense and slightly red, tender but not warm, not pulsating, and with no bruit was found on the left lower chest and upper abdomen laterally. The spleen was enlarged 8 cm below the costal margin. Other systems were normal.\nChest X-rays showed a calcified lesion near the hilum of the right lung suggestive of an old pulmonary tuberculosis. Abdominal radiographs showed calcified lesions in the left upper quadrant (). Ultrasound of the abdomen indicated an enlarged spleen with areas of calcification. CT scan of the abdomen revealed a splenic abscess communicating with another subcutaneous abscess through the lower chest wall (). Based on these data, a complicated tuberculous splenic abscess was the most probable diagnosis.\nUnder general anesthesia, the subcutaneous abscess was incised and drained, and splenectomy was performed simultaneously. The spleen was found to be enlarged, fibrotic, and adherent to the lower chest wall. There was an abscess cavity within the spleen communicating with the subcutaneous abscess through a small tract in the lower chest wall below the insertion of the diaphragm. The abscesses contained thick pus and necrotic material. Histopathology of the spleen revealed the characteristic tuberculoid granuloma with epithelioid cells, Langhans’ multinucleated giant cells, and caseation necrosis (). Acid fast bacilli staining, tuberculous and bacterial cultures were all negative.\nThe patient was started on Isoniazid (INH) 300 mg OD, Rifampin 600 mg OD, Ethambutol 600 mg OD and Pyrazinamide 500 mg OD for 5 weeks, then maintained on the former two drugs. The patient's condition improved on anti-tuberculous medications and showed good clinical progress at one-year follow-up.
The patient is a 59-year-old male with a large partially cystic right medial frontal glioblastoma multiforme (GBM) who presented to an outside hospital with 1-month progressive altered mental status, syncope, and difficulty ambulating. By the time he presented to our care, he was noted to have limited functional mobility, minimal spontaneous movements, and was unable to talk or to follow commands. Preoperative imaging demonstrated the GBM's involvement of most of the medial frontal lobe, the anterior cingulate, and genu of the corpus callosum (Figure ).\nFollowing surgery, postoperative imaging was obtained for the patient, which demonstrated excellent tumor resection, with no evidence of the removal of the basal ganglia, ischemic stroke, or hematoma (Figure ). Despite this, he remained in poor neurologic condition and required reintubation to protect his airway due to unresponsiveness. Eventually, he required a ventriculoperitoneal shunt placement and a percutaneous endoscopic gastronomy placement as he was unable to remain alert for feeding. The postoperative course was complicated by hydrocephalus, severely elevated intracranial pressure and dysphagia, requiring an external ventricular drain.\nSeven weeks following surgery, he remained in as poor a neurologic condition as when he initially arrived, and it was determined that because he had made no progress. His Karnofsky performance status (KPS) was an abysmal score of 20, and he was not a candidate for adjuvant therapy for his glioma. We had repeatedly imaged him to show that his shunt appeared to be working, and there were no obvious other structural causes of his poor neurologic condition. Continuous electroencephalogram had been unrevealing. Repeated cerebrospinal fluid sampling had never shown any sign of infection. Multiple rounds of laboratory studies had shown no evidence of metabolic causes of his poor status such as hepatic dysfunction, electrolyte, thyroid, or adrenal disturbances. We had eliminated all sedating medicine. In short, there was no obvious confounding causes of his poor neurologic condition other than the injury caused to his frontal lobe by the tumor and its removal.\nHe had been waiting in the hospital for placement in a long-term care facility for 2 weeks when we became curious about whether there was anything that could be done for him, so we obtained a rsfMRI image. When this was processed using ICA, we found that none of the components contained a set of activated areas suggestive of the DMN in either hemisphere. While ICA can sometimes split components, our experience with clinical grade images processed in this way is that the DMN is always present. For this reason, we hypothesized that loss of the anterior medial frontal component of the DMN had caused the loss of a coherent DMN bilaterally.\nWe discussed the idea of attempting to treat this with the family. More specifically, we discussed using repetitive TMS in an off-label use to try to improve his neurologic function. We told them that this was a completely experimental use of the device; however, given that without neurologic improvement, his death was certain. We discussed that we had no other therapies to offer to try to make him better and that it is unlikely that the treatment would worsen his grim natural history. They were willing to try this treatment option.\nThe DMN classically is made up of three main areas per hemisphere (the medial frontal/anterior cingulate (ACC), the posterior cingulate (PCC), and the inferior parietal lobule (IPL)). Two of these are typically inaccessible to most forms of TMS, namely the ACC and PCC portions which lie in the interhemispheric fissure. For this reason, we decided to perform a stimulatory treatment aimed at the only part of the DMN accessible to us, which was the IPL. We utilized 200 pulses of iTBS to the right IPL, specifically the superior angular gyrus, for a total of 5 sessions. There were no complications during the sessions.\nAfter the first treatment session, the patient began speaking single words and following simple commands. Prior to discharge after the 5 sessions were completed, this patient showed some improvement in motor function and intermittently was following commands. This enabled him to participate with some physical and speech therapy.\nHe returned 2 weeks later and was dramatically improved. He was able to sit up and hold detailed conversations with the neuro-oncologist about the risks and benefits of chemotherapy for his tumor. His KPS had improved to 80, and he had begun to walk and regain some strength.\nWe repeated a rsfMRI and were able to locate a clear DMN component in our ICA analysis (Figure ). In addition to containing activation in the bilateral IPL's, this component contained bilateral activation in the PCC's and the right medial frontal lobe/ACC, suggesting that the DMN was a coherent independent component.
A nine-year-old male presented to the pediatric outpatient department of our tertiary care hospital with complaints of sleep disturbances for the past four years and poor scholastic performance for the past two years. He had change of school two years back to a tougher curriculum. He was currently studying in fourth grade and was managed with various medications which offered no relief. There was no history of fever, seizures, altered sensorium or atopic conditions. He had no symptoms of gastrointestinal disturbances, head injury, substance abuse or chronic drug intake. Sexual abuse was also ruled out by detailed evaluation by a child psychiatrist. Detailed sleep history and review of sleep diary revealed his difficulty in falling asleep for nearly four to five days per month, characterized by being completely awake for two days even without short naps in between. This did not affect his routine in the subsequent days. He had difficulty in Mathematics and English in academics. He was the first sibling and the index case for high scholastic expectations from his parents. There was no history of inattention, hyperactivity, mood changes or history of being bullied by his friends. He was the first born of a third-degree consanguineous marriage, with a four-year-old younger brother. His perinatal period was uneventful with normal development. There were no conflicts, recent deaths or history of sleep problems in the family. His screen time was two hours per day, and both brothers shared the same room without television. There was no excessive intake of caffeine.\nOn examination, he was a cheerful co-operative child, moderately built and nourished with a weight of 26 kg and a height of 126 cm. There was no pallor, facial dysmorphism or neurocutaneous markers. His vitals, anthropometric measurements and systemic examination were within normal limits. His behavioral observation showed that his attention was easily aroused with sustained eye contact. He was able to comprehend and follow instructions adequately. Investigations such as serum hemoglobin, ferritin, vitamin B12, vitamin D levels, hepatic and renal parameters with electrolytes were normal. The MRI scan of the brain and the sleep electroencephalogram (EEG) showed increased cortical arousal during the sleep onset period.\nThis child was simultaneously evaluated in our child development unit for his difficulty in scholastic performance. Wechsler Intelligence Scale for children (WISC-4 India) was administered where he obtained an overall intelligence quotient (IQ) score of 88 (below average) with some scatter in the subscales []. Dyslexia Screening Tool Junior (Indian version) showed “at risk quotient” (ARQ) of 1.4, which indicates "strong risk." Sentence Completion Test Junior showed no significant conflicts in school adjustments. He found Mathematics difficult but had a positive attitude towards his future professional achievements. He was preoccupied with sleep problems and had fears related to darkness. No significant emotional themes were identified in Children’s Apperception Test (CAT). Controlled Projective Test (CPT) showed his prominent need for affiliation with peers to resolve conflicts and his potential fear of being rejected by peers. Conners Self-Report Scale showed that he did not report any specific concerns. Our patient was diagnosed to have chronic insomnia by the International Classification of Sleep Disorders (ICSD-3) criteria []. His symptom characteristics like exaggerated physiological arousal, learned sleep preventing measures, excessive worry regarding sleep and a heightened concern regarding daytime consequences fit in with psychophysiological type of insomnia [].\nThe results were discussed with his parents who were advised to have realistic academic expectations. They were advised to avail remedial education services as his sleeplessness could be a manifestation of underlying academic stress. The child was advised sleep hygiene measures with a prescription of melatonin (3 mg) orally once a day for 10 days, to be taken an hour prior to sleep to regulate his sleep pattern. As child development follows a biopsychosocial trajectory, his symptoms were managed accordingly which benefited the child. On review at three months, his sleep schedule was regular and he was coping better with academics. Thus a multidisciplinary approach, ruling out all organic etiologies and a detailed probe into his academics helped in the diagnosis of psychophysiological insomnia with specific learning disability.
A 24-year-old healthy woman presented with difficulty breathing and dissatisfaction with her facial appearance. She had a history of childhood trauma resulting in nasal septum deviation and external nasal deformity. Four months after a successful and uneventful septorhinoplasty, she presented to the emergency department with blunt nasal trauma resulting in a septal hematoma, which was drained successfully; the patient was discharged with no adverse sequelae.\nFour months later, the patient sustained nasal trauma again, this time accompanied by clear nasal discharge, raising suspicion of cerebrospinal fluid (CSF) leak. The patient was discharged after managing the nasal injury, as the CT brain showed an intact cribriform plate with no evidence of a CSF leak. Ten days later, she presented at the emergency department with dizziness and an unstable gait. She also had complaints of paresthesia for the past two months, beginning in her right hand and progressing to the right shoulder, arm and leg, associated with some difficulty in the execution of movements in the first and second finger of the right hand. Her right leg was quite stiff with difficulty in walking. On close inquiry, she gave history of pain in the right eye and double vision many months back, which had resolved spontaneously. Examination showed a positive Romberg’s and Lhermitte’s sign, with right-sided sensory impairment.\nMagnetic resonance imaging (MRI) of the brain, cervical and thoracic spine demonstrated demyelinating lesions in the brain and cervical segment of the spinal cord (Figure ). Some of the lesions demonstrated enhancement on post gadolinium administration sequences, suggestive of active demyelinating diseases like MS. A lumbar puncture was performed which demonstrated the presence of oligoclonal bands in the CSF. The diagnosis of MS was confirmed by a neurologist and treatment was initiated.\nThe initial neurological symptoms have largely vanished with only persistent light paresthesia in the right hand. Two years later she has had no new symptoms and continues with the same medication with good tolerance.
An 84-year-old male patient with past medical history consisting of hypertension, hypercholesterolemia, type 2 diabetes mellitus, and open angle glaucoma was admitted to ICU via A & E with an unwitnessed collapse and decreased level of consciousness. In emergency department (ED) his GCS was recorded as 5/15, blood sugar was found to be only 34 mg/dL, his heart rate was 34 beats per minutes (bpm), and BP was 58/43 mm Hg. His ECG showed sinus bradycardia with variable blocks including sinus node dysfunction and type 1 Mobitz heart block pattern (Figures and ). He was intubated and ventilated in ED and given dextrose 50% 100 mL and 0.5 mg Atropine. His heart rate rose to 88 bpm and with improvement of heart rate and correction of blood sugar his BP became 135/88 and his GCS improved to 13/15. Unfortunately, heart rate started to drop again to 40 s and blood sugar showed a downward trend for which he was given 1 mg glucagon and was transferred to ICU. By the time he reached ICU his heart rate had improved to 90 bpm. In ICU after 30 minutes his heart rate dropped again so he was given another dose of Atropine and a temporary transvenous pace maker (TPM) was inserted. The patient's blood sugar also improved temporarily but eventually required intravenous infusion of 10% dextrose for the next 12 hours before it was stabilized. His GCS improved to 14/15 and he was extubated the next day 16 hours after admission but repeated attempts to switch off his pace maker revealed underlying brady-arrythmias with heart rate dropping to 34–40 bpm associated with presyncopal symptoms comprising of deterioration in attention and episodes of drowsiness. The pace maker was eventually switched off after 26 hours of observation when no more episodes of bradycardia were observed.\nA detailed neurological assessment was carried out after extubation which showed the patient to be confused with no motor deficit. His CT brain was done which showed no abnormality and a detailed history was sought from the patient's wife who pointed out that the patient has been behaving in a weird and confused way for the last 5 days but his wife attributed that to demise of one of his close relative who died a week ago. She further added that he stopped taking his oral medications 2 days before he was admitted but he was given his eye drops regularly by his daughter who feared blindness in case the medication was not given. His drug history consisted of Enalapril 10 mg OD, Atorvastatin 10 mg OD, Metformin 500 mg BID, and Timolol Maleate 0.5% one drop each eye twice a day which was started 35 days before admission to ICU when he was diagnosed as a case of glaucoma.\nTilt table test was not carried out and keeping in view his improvement in blood sugar and heart rate after administration of glucagon his clinical picture of hypoglycemia, confusion, and bradyarrhythmia was recognized to be because of ophthalmic Timolol Maleate which was changed to Travoprost (a prostaglandin F2 analogue) after consulting the ophthalmologist.\nThe patient was kept under observation in ICU for another 24 hours. His intrinsic heart rate improved to 82 bpm and his TPM wire was removed before transferring to ward. Patient's confusion also improved gradually over the next 3 days and he was discharged on Enalapril, Travoprost, and Metformin. His followup for the next two months was unremarkable.
A 38-year-old man was found to have a uterus, fallopian tubes, and a gonad in the left hernial sac during herniorrhaphy. The patient developed a left scrotal sac swelling postoperatively.\nOn physical examination, the right scrotal sac was empty. The left scrotal sac appeared boggy. The patient was phenotypically male, with male pattern of external genitalia and secondary sexual characteristics. The past history included primary infertility.\nUSG showed a well-formed uterus situated alongside the bladder and extending into the inguinal canal []. The endometrial cavity was distended with a small collection []. An oval structure with uniform internal echoes, conforming to a testis, was noted at the level of the left deep inguinal ring []. The prostate and seminal vesicles were well visualized and appeared normal. The left scrotal sac showed a septate collection, consistent with a hematocele. No testis was identified within the left scrotal sac. The right scrotal sac was empty. The right testis could not be identified in an ectopic location.\nMRI confirmed the USG findings. It showed a well-formed uterus and fallopian tubes alongside the urinary bladder and extending into the left inguinal region []. A small collection was noted in the uterine cavity []. An oval structure measuring 3.7 × 1.9 cm, with morphology and signal intensity consistent with a testis was detected at the level of the deep inguinal ring []. A vagina-like structure was seen extending from the uterus toward the left seminal vesicle []. No structure conforming to the testis was seen in the scrotal sac or in any ectopic location. The right gonadal vessels were seen ending blindly in the right iliac fossa, which confirmed the diagnosis of a vanishing right testis. The seminal vesicles and prostate appeared normal. No structure with ovarian morphology was seen. The collection in the left scrotal sac showed features and signal intensities of a hematocele.\nExploratory laparotomy/excision was planned for the patient subsequently. However the patient refused a second surgery.
A 44-year-old male was admitted to our hospital because of recurrent abdominal pain for more than two years that worsened over the past two weeks. He was a heavy drinker, with alcohol consumption of 250 g/day for 15 years. He had no history of trauma but previous 3 episodes of pancreatitis. He had the first episode of acute pancreatitis two years ago and received conservative treatment for it. The second episode of acute pancreatitis, about one and a half years ago, was accompanied by retroperitoneal cyst and splenomegaly along with dilation of the pancreatic duct. During the second episode, he underwent pancreatic duct dilation with a stent implanted into the pancreatic duct that was removed after 4 months. During the third episode of acute pancreatitis, about six months ago, a large pseudocyst was seen in the body and tail of the pancreas. Patient's symptoms were relieved after symptomatic treatment, but pseudocyst had not been treated. Nearly two weeks ago, the patient had recurrent upper abdominal pain, which was persistent and radiating to the left shoulder and back. He was admitted to local hospital. The routine blood test showed hemoglobin 102 g/L and serum amylase 139 U/L. Abdominal CT showed a large pseudocyst in the body and tail of the pancreas with signs of bleeding, a large subcapsular hematoma of the spleen, and cholecystitis with gallstones. Despite the conservative treatment consisting of pain control, bowel rest, intravenous fluids, and antibiotics, the pain was not relieved, so he visited our hospital.\nAfter admission, his blood pressure, pulse rate, and body temperature were 117/69 mmHg, 58 beats per minute, and 36.5°C, respectively. The abdominal examination revealed a palpable mass in the left upper quadrant with mild tenderness. The spleen was palpable under the left costal arch. Murphy's sign was negative. The laboratory findings showed that the liver function tests, renal function tests, and electrolytes were within normal limit. However, there was a leukocytosis (12500/mm3), increased C-reactive protein (10.1 mg/dL), and decreased hemoglobin (9.1 g/dL) and hematocrit (26.9%). The serum amylase was 117 U/L, which were slightly above the normal range. The endoscopic ultrasonography revealed gastric vein varicosis in the fundus, pancreatic pseudocyst, cholecystitis with accumulation of biliary sludge, splenomegaly with subcapsular hematoma, and splenic vein varicosis. The CT-Abdomen revealed a huge low-density mass (16.0 × 16.0 × 7.6 cm) with some separations and loss of normal pancreatic morphology in the body and tail, splenomegaly with subcapsular hematoma (13.5 × 10.0 × 8.0 cm) that possibly pressurizes the left kidney, multiple cysts seen in the liver, gallstones, abdominal and pelvic effusion, bilateral pleural effusion with lungs atelectasis, splenic vein dilation, and expansion of portal vein branches (Figures –).\nDuring hospitalization, EUS-guided pseudocyst puncture and drainage were done, where small amount of dark brown liquid was collected. The following day CT-Abdomen showed no changes in the pancreatic pseudocyst and splenic subcapsular hematoma, while the NG tube was still in place (). Splenic artery embolization () was done on the next day, with no significant changes on the follow-up CT-Abdomen result. About 4 days later, ultrasound-guided percutaneous puncture drainage of pancreatic pseudocyst was done (). Postoperative fluid collection was about 5000 ml of dark brown liquid with amylase 21577 U/L, lipase 56704 U/L, red blood cell count 0.45 × 1012/L, and hemoglobin 29 g/L. The follow-up CT-Abdomen (plain + contrast), about 2 weeks later, showed the disappearance of pancreatic pseudocyst and multiple areas of infarction on the spleen, while the splenic subcapsular hematoma had significantly reduced (). Abdominal ultrasound was done to obtain detailed status of the subcapsular hematoma. During hospitalization, the patient was also supplemented by antibiotics, nutritional support, acid suppression, and inhibition of pancreatic secretion. The patient was discharged after almost a month of his hospital admission with the drainage tube attached, and about 2 weeks later the drainage tube was removed upon CT scan confirmation of decrease in the volume of the subcapsular hematoma (). Patient had no abdominal symptoms at the 1.5-year follow-up.
A 50-year-old man presented to the emergency room with several months of intermittent fever and progressive lower back pain. He described a mechanical fall one week prior to this admission. He had a medical history of alcohol abuse, intravenous drug use, hepatitis C infection, and native tricuspid valve infective endocarditis secondary to methicillin-resistant Staphylococcus aureus (MRSA) five months prior to his current hospital admission. At that time, his transthoracic echocardiogram showed a tricuspid valve vegetation measuring 11 × 6 mm with severe tricuspid regurgitation. He was partially treated with intravenous vancomycin followed by daptomycin with serial negative blood cultures. Magnetic resonance imaging (MRI) of his spine at that time showed no evidence of vertebral osteomyelitis or epidural abscess.\nTwo months prior to the current hospital admission, he presented to the emergency room with back pain. At this time, his blood cultures were positive for the growth of V. dispar, which was identified by matrix-assisted laser desorption/ionization-time of flight mass spectrometry. A transthoracic echocardiogram was performed prior to him leaving the hospital against medical advice and showed that the tricuspid valve vegetation was now smaller in size, measuring 7 × 6 mm (Figure ). He received no antimicrobial treatment at this time.\nDuring his current hospital admission, he was visibly agitated on physical examination and described significant lower back pain. His initial vital signs included a temperature of 39.5 degrees Celsius, heart rate of 120 beats per minute, respiratory rate of 20 breaths per minute, oxygen saturation of 97% on ambient room air, and blood pressure of 106/68 mmHg. His neck was supple and his neurological examination demonstrated normal tone throughout his upper and lower extremities. Strength in his right lower extremity was 3/5 for ankle plantar flexion and dorsiflexion, 2/5 for knee extension and flexion, and 3/5 for hip extension and flexion. His strength was 4/5 throughout his left lower extremity. His sensation was normal apart from decreased light touch sensation to his medial right gastrocnemius region. He had spinal and paraspinal tenderness in his mid and lower back. His reflexes were 2+ in his knees and plantars were down-going bilaterally. He had a grade III/VI systolic murmur best heard at the left lower sternal border. Air entry was equal and clear bilaterally with fine crackles to his right lower lung zone. No other peripheral stigmata of infective endocarditis were present on examination. Examination of the oral cavity showed he was missing upper teeth with overall poor dentition. Initial laboratory investigations are summarized in Table .\nHis electrocardiogram was normal. During his hospital admission, two sets of blood cultures obtained 96 hours apart were again positive for the growth of V. dispar. Given his persistent bacteremia, a transthoracic echocardiogram was performed which showed growth in the size of the vegetation previously noted on his tricuspid valve, now measuring 11 × 7 mm. There were also signs of torrential tricuspid regurgitation including a vena contracta width greater than 0.7 cm, a central jet that was filling greater than 50% of the right atrium, and a triangular-shaped continuous-wave Doppler signal which was as dense as the inflow signal along with evidence of systolic hepatic vein flow reversal (Figures , ).\nAn MRI scan of the spine showed early discitis/osteomyelitis of L3-L4 with a right paravertebral and right paracentral anterior epidural phlegmon with no abscess (Figure ). The neurosurgical team assessed the patient and recommended conservative management with ongoing antimicrobial therapy and physiotherapy, and monitoring for any worsening neurological deficits. In addition, given his poor dentition, a computed tomography (CT) scan of the brain, head, and neck was arranged, which showed no obvious evidence of an abscess collection within the neck, oropharynx, or brain. Furthermore, no septic pulmonary emboli were seen on imaging.\nSusceptibility testing was performed on his V. dispar isolate using broth microdilution and showed susceptibility to penicillin (minimum inhibitory concentration [MIC] < 0.5), amoxicillin-clavulanate (MIC < 4/2), and metronidazole (MIC < 8) compared against breakpoints according to the Clinical and Laboratory Standards Institute. He was treated with intravenous ceftriaxone for six weeks with clinical improvement noted within a few days following his admission. The patient reported near-complete resolution of his back pain and his repeat C-reactive protein level toward the end of therapy was 3.8 mg/L (normal 0.0-7.0 mg/L). Subsequently, he developed a central-line-associated bloodstream infection secondary to Candida dubliniensis with no evidence of endophthalmitis, for which he received a two-week course of intravenous caspofungin.\nA repeat MRI was arranged after his therapy which showed resolution of the anterior epidural phlegmon but interval worsening of the L3-L4 discitis/osteomyelitis with a new enhancement of the L3 and L4 facets without effusion (Figure ). A subsequent CT-guided lumbar spine biopsy of the L3/L4 region was performed, and bacterial, fungal, and mycobacterial cultures were negative. A repeat transthoracic echocardiogram was planned to establish a new baseline for his valvular anatomy given his risk of recurrent endocarditis; however, the patient left against medical advice.
An 18-month-old girl child presented with rapidly progressive bilateral lower limb weakness with fever for 2 months. The mother of the child also noticed that she was not feeling any sensation below the nipples and had bladder incontinence. The fever was intermittent and the child was on several antibiotics without any benefit. Neurological examination showed conscious and active child. She had flaccid paraplegia with grade “0” power with absent deep tendon reflexes. Sensory examination showed absent sensation to pain below D4 level on both sides. Power, tone, and sensation were normal in the upper limbs. There were no signs of meningeal irritation. Careful examination of the back showed a very small dermal sinus in the lower lumbar region, discharging pus on digital pressure. Magnetic resonance imaging (MRI) showed multiple coalescing ring enhancing lesions in the spinal cord extending from D4 to L5 with cord edema upto cervical level []. The differential diagnosis considered were holocord glioma and holocord abscess. Modified osteoplastic laminotomy, described by Raimondi et al.,[] was performed from D4 to L5 []. The dermal sinus tract was seen to extend from the skin at L5 and end intradurally at the same level. Dura was opened and there was dermoid material and pus in the lumbar region The spinal cord was found to be diffusely enlarged. Myelotomy was performed at different levels and pus was evacuated from the spinal cord []. There were extensive arachnoidal adhesions. In view of the extensive nature of the abscess, no attempt was made to excise the abscess capsule. The dura was closed with fascial graft. The laminotomy flap was replaced []. The child stood the surgery well and the postoperative period was uneventful. Escherichia coli and Pseudomonas aeruginosa were grown on culture. She was started on antibiotics as per the sensitivity report. She started showing some neurological improvement within a few days in the form of some movement in both the legs. She was on long-term antibiotics for 8 weeks and physiotherapy. At 2 months follow-up, she had grade 3 power in the right lower limb and grade 1-2 power in the left. Sensory level was at D12 both sides. Follow-up MRI shows good resolution of the intramedullary abscess [].
A 74-year-old female patient who had been followed at our private clinic for AD for the past two years, recently presented to her follow-up visit with the complaints of displaying hypersexual behavior to the females around her, including her female caregivers and adult granddaughters. According to the history obtained from her caregivers, this hypersexuality involved not only flirtatious remarks to females but also included attempts to touch their breasts and genitalia. The family was at first terrified and baffled by these new symptoms and preferred to ignore when they first became apparent in the past few months, but later on wanted to seek professional help as it was getting harder for them to find professional female caregivers to take her on; and also leading to social isolation of the family members. Eventually she was taken to a nursing home, where she continued to display ISB toward the female staff. During the clinical visits, she also made compliments to the female staff members and expressed a desire to be physically intimate with them.\nPast history obtained from her son and daughter-in law revealed that she married with her first boyfriend when she was 17 years old and stayed married for 43 years until her husband passed away 14 years ago. Both of them were born and raised in Romania, but then immigrated to Turkey when she was at the age of 40. Reportedly, she had a decent and happy marriage and raised three children with her husband. She continued to work as a nurse in Turkey for 17 years until her retirement. After her spouse’s death, she moved back and forth between Romania and Turkey spending half of the year at two homes in each country for a while but she was finally settled down permanently in Turkey in the past 8 years. She did not have another boyfriend after her spouse’s passing and refused getting married, stating that her husband was the one and only love in her life.\nShe was reported to act oddly for a brief period of time soon after her spouse’s death, blaming him for leaving her alone or trying to look attractive during the funeral; but they did not seek medical attention for these and she was reported to be “normal” until she had a hip joint replacement surgery 7 years ago. After the surgery, she became increasingly forgetful, started repeating the same sentences over and over, and lost her purse several times. There was a change in her character as well; always being a cheerful and outgoing person, she started to be less social. With these complaints, they saw a neurologist 5 years ago and a diagnosis of AD was made and she was started on donepezil 5 mg initially which was increased to 10 mg after a month. Two years ago, she developed anxiety symptoms and an increasing restlessness and visual hallucinations and a 20 mg of citalopram was added to her drug regimen which helped with her anxiety symptoms but paranoid delusions associated visual and auditory hallucinations spiked up and that was when she was referred to our clinic for the first time.\nAt her first presentation two years ago, she was on 10 mg of donepezil, 40 mg of citalopram daily. She had severe memory deficits and visual and auditory hallucinations during the night time. She also had paranoid delusions. She closed her windows and curtains tightly because she supposed someone was chasing after her. She reportedly also started to show interest in clothes and underwear with flamboyant colors. The patient had three siblings, two of which were also diagnosed with AD; however genetic testing was denied by the family. Neuropsychological assessment demonstrated severe memory impairment, moderate deficit in executive functions, visuospatial ability, attention, and concentration. She scored 13 on the Mini-Mental Status Examination (MMSE) and 2 on the Clinical Dementia Rating Scale (CDR). She was recommended to take memantine (with a dose to be gradually increased to 20 mg within a month) and 25 mg quetiapine at night time. After 15 days from her new medication, hallucinations and delusions were gone.\nHer present visit was mainly due to these recent ISB. Her neuropsychological evaluation remained unchanged with a MMSE of 13 and a CDR of 2.\nRoutine blood tests (complete blood count, electrolytes, renal and liver function tests and vitamin B12 and folate levels) were within normal limits. Her EEG demonstrated diffuse background slowing without epileptiform activity.\nAn MRI scan was ordered to rule out any superimposing organic pathologies such as a recently developed infarct or a space occupying lesion; however it was unremarkable except signs of small vessel ischemic disease involving the periventricular white matter with scattered foci of T2 hyperintensities throughout the deep and subcortical white matter and moderate volume loss more prominently involving the mesial temporal structures ().\nHer medication was re-evaluated and quetiapine 25 mg that she had been on for 2 years, was stopped and she was prescribed aripiprazole with a dose of 2.5 mg to be gradually increased to 10 mg within a month. Phone interview about 2 weeks after the initiation of the aripiprazole treatment revealed that sexual remarks to the female staff members and other disinhibitory features subsided. She was less likely to get into physical contact with the female staff and other female residents of the nursing home, and her restlessness also improved. During the follow up visit after two months of the treatment, she was reported to be free of the symptoms without any ISB in the nursing home. She had increased personal interactions with other residents and the staff of both genders, without evolving into a disturbing point. No side effects were reported.
The first case we present is that of a 29-year-old woman who presented to the clinic with the complaint of an enlarging left breast mass. She first noticed that this mass almost 2 years ago and mentions that it has been growing in size and becoming more erythematous and tender. She did not report any recent weight loss or change in appetite. She is married with 2 children, and she does not have any illnesses. She smokes hubble-bubble almost 4 times per week and does not drink alcohol. Surgical history is significant for 2 previous Cesarean sections with no complications. History of her current illness dates back to June 2016 when the patient felt a mass in her left breast; upon further investigation, she was diagnosed with idiopathic granulomatous mastitis and later (December 2017) developed an abscess that drained on its own. She was initially treated with methotrexate and later switched to prednisone and mycophenolate with minimal improvement. At the clinic, her vitals were within normal limits, and on physical examination, there was a left breast lump found at the upper inner quadrant with some erythema and inflammation surrounding it. Moreover, there was some skin retraction in this area.\nCore biopsy done at an outside hospital in June 2017 revealed no granulomas. Ultrasound done at that time showed a persistent ill-defined hypoechoic mass that appeared initially subdermally and was spanning more than 4 × 1.4 cm. Moreover, multiple deeper masses were seen, one of which was not located within the breast measuring 12.3 × 8.5 mm. Axillary nodes were insignificant and not well appreciated on imaging.\nFine-needle aspirate done in July 2017 was negative for malignancy and was reported to have abscess formation. The slides revealed a heavy inflammatory infiltrate predominantly composed of polymorphonuclear leukocytes. No ductal epithelial cells were seen.\nCore biopsy done in November of the same year showed multiple noncaseating epithelioid granulomas composed of epithelioid histiocytes, lymphocytes, neutrophils, and occasional multinucleated giant cells. Some granulomas contained neutrophils forming microabscesses with surrounding empty microcysts ().\nThe Ziehl–Neelsen stain for acid-fast bacilli was negative. This leads to the diagnosis of idiopathic granulomatous mastitis which is a diagnosis of exclusion.\nA repeat MRI done during June 2018 showed heterogeneous fibroglandular tissue with mild background enhancement. There are also numerous tiny rim-enhancing fluid collections in the left breast, the largest measuring 8 mm involving the upper inner and lower inner quadrants, some of which are fistulizing to the skin. Findings have regressed compared to the prior MRI.\nAs with the previous MRI, no enlarged axillary or internal mammary adenopathy was seen.\nThose findings are consistent with biopsy-proven idiopathic granulomatous mastitis extensively involving the upper and lower inner quadrants of the left breast.
A 69-year old Caucasian female was admitted to the emergency department due to fall from 50 cm height and she was complaining of intense pain in her right flank around the impact area. The examination revealed pain in the lower right thoracic area and right upper quadrant in superficial and deep palpation with no sign of abrasions or ecchymosis. Her vital signs, on presentation, were slightly abnormal (Blood pressure: 150/83 mmHg, Heart rate: 84 bpm, SpO2: 97 %, Body Temperature: 36.7 °C). The patient’s medical history consisted of hypertension under medication and chronic obstructive pulmonary disease (COPD) due to smoking. She did not mention anti-coagulant or anti-platelet use. Chest radiograph showed minor right pleural effusion without rib fractures and FAST did not reveal any evidence of trauma. There were no abnormal findings from her blood analysis, metabolic/coagulation panel, and urinalysis. The patient constantly complained about pain in her right upper quadrant and right flank even after the administration of analgesics. A thoracoabdominal CE-CT was performed to evaluate the origin of pleural effusion and abdominal pain. The CT confirmed the pleural fluid diagnosis as well as mentioned a small round lesion of variable attenuation with a very small focal hyperdense area on the right adrenal, with no active extravasation (). No other traumatic injuries from the chest or abdomen were described. The patient was admitted to the clinic for monitoring. She remained hemodynamically stable but complained of pain and difficulty in deep breath even with IV analgesia. Therefore, a thoracoabdominal CT scan was scheduled. The right adrenal lesion appeared as a more well-defined hypodense oval mass, possibly adenoma, while the rest of the gland was slightly enlarged and hyperdense (). The possibility of mild adrenal contusion was discussed. The pleural effusion remained unchanged and treated conservatively. No other evidence of trauma was concluded from the rest of the radiographic examination. Hyponatremia and hypokalemia remained even after fluid and electrolyte administration but otherwise she had normal lab values. The patient’s pain improved after three days and was discharged after a 5-day hospitalization with oral antibiotic and pain medication. Unfortunately, the patient was lost on scheduled follow-up.
A 66-year-old female, referred by the department of medicine, presented with fluid-filled lesions on the right side of the face following intense pain. She was unable to open the right eye. Dermatological examination revealed multiple grouped papules and vesicles on the erythematous base covering the right side of the forehead, the upper eyelid, and the side of the bridge of nose, nasal aperture, and vestibule. Tzanck smear from vesicular lesions revealed multiple multinucleated giant cells. On ophthalmic examination, there was edema of right upper lid along with conjunctival congestion and corneal clouding. General physical examination was normal. Systemic examination revealed no organomegaly or lymphadenopathy. Routine investigations were within the normal limits. A diagnosis of HZ ophthalmicus was made, and the patient was prescribed oral acyclovir 800 mg 5 times a day for 7 days along with anti-inflammatory agents, topical silver sulfadiazine cream, and eye drops. Two days later, she developed superficial punctate keratitis showing positive fluorescein staining. Slit lamp examination revealed changes of senile cataract. Fundus examination was normal. On follow-up at 1 week, corneal edema subsided completely, conjunctival congestion markedly decreased, and she was able to easily open the eyes. Skin lesions began to crust and showed early signs of healing. The patient was given amitriptyline 25 mg twice daily and carbamazepine 200 mg thrice daily to relieve neuralgic pain. Two weeks after the onset of eruption, lesions on the right side of the forehead and the right eyelid had healed, but there was crust formation along with deep ulcerative lesions on the right nasal aperture. The formation of the ulcerative lesions prompted us to do a complete workup of the patient to check her immunological status, which we had not done at the initial presentation as HZ is common in elderly and we did not suspect any kind of immunosuppression. Her past history did not reveal any such history of similar lesions, radiotherapy, blood transfusion, antitubercular treatment, chemotherapy, surgery, and chronic medical treatment. Pus swab for culture and sensitivity from the ulcerative lesions showed normal flora. Repeat complete hemogram, blood glucose, erythrocytesedimentation rate, and skiagram of the chest were done. Additionally, mantoux test, venereal disease research laboratory test (VDRL), and ultrasonography of the abdomen were done, but they did not reveal any abnormality. The patient was seronegative to HIV-1 and HIV-2. A diagnosis of necrodestructive HZ was made. After about 6 weeks, lesions on the entire affected area healed with depressed superficial scarring along with hyper- and hypopigmented macular lesions, but the patient had extensive scarring on the right side of the anterior nare. She was unable to breathe from the right side due to almost complete obstruction of the right anterior nare []. A small plastic tube was inserted inside the right anterior nare to keep the nasal passage patent. On repeated follow-ups, there was no improvement in the obstruction of nasal aperture. The patient was then referred for plastic surgery for reconstruction.
A 58-year-old female presented to the emergency department with intermittent, crampy right-sided abdominal pain, nausea, and vomiting, which began approximately 18 hours previously. Her past medical history was significant for hypertension and her surgical history included a thyroidectomy for treatment of thyroid cancer and a Caesarean section. A contrast enhanced CT abdomen and pelvis was obtained, demonstrating multiple fluid-filled, dilated small bowel loops in the right abdomen, which were predominantly anterolateral to the ascending colon and cecum (). In addition, two transition points were identified in the right lower quadrant, with one transition point at the distal ileum just proximal to the cecum and a second transition point in the proximal ileum. The two transition points were in close proximity to each other, indicative of closed loop obstruction. Decreased wall enhancement of the dilated small bowel loops was concerning for ischemia. Mucosal hyperenhancement of the ileum at the proximal transition point was felt to relate to ischemia or decompressed state (). Given the patient's symptoms and findings of closed loop obstruction on CT, the patient was taken to operating room. In the operating room, an internal hernia with closed loop obstruction was confirmed and resulted from herniation of small bowel through an adhesion of a transverse colon epiploic appendage to the ascending colon mesentery. The herniated small bowel was nonviable and a total of 60 cm of small bowel was resected (). Retrospectively, kinking of the ascending and transverse colon could be seen on the initial abdominal CT and was felt to correspond with the site of adhesion ().\nAfter resection, the patient's small bowel was left in discontinuity and an abdominal wound-vac was placed. The following day, the patient returned to the operating room, at which time the terminal ileum was also found to be nonviable. An ileocecectomy with enterocolonic anastomosis was performed.\nThe patient had a complicated postoperative course, but was ultimately discharged approximately two weeks after the initial surgery.
A 25-year-old Hausa apprentice boy was referred to us on account of failure to micturate and a discharging wound on the right side of the root of the penis. He was knocked off the road about six months prior to presentation, by a fast moving vehicle while riding bicycle on the highway. There was no known premorbid condition in him. He lost consciousness immediately and also sustained closed fracture of the left femur. He had initial resuscitation at the referring centre, where urethral catheter was passed among other things. The relation gave history of blood stained urine after the initial catheterization. He was on admission for about twelve weeks before he regained full consciousness. He was discharged against medical advice from the centre because he wanted to manage the bone fracture locally by the traditional bone setter.\nHe noticed difficulty with micturition soon after the urethral catheter was removed; this was characterised by occasional straining and passage of scanty urine. This necessitated presenting again in the hospital where he was recatheterised but no urine came through the catheter. At this time, he also noticed to have persistent and frequent passage of watery stool, appearance of boil at the root of the penis which later burst. There was associated fever with chills and he was unable to walk with the left lower limb.\nAt presentation to us, he was looking toxic, pale, and dehydrated with deformity of the left thigh the temperature was 38°C, pulse was 94 per minute, blood pressure was 110/60 mmHg and the chest was clinically clear, no murmur or gallop rhythm. There was right renal angle tenderness; the rectum was empty with no organomegaly. The urethral catheter was not functioning; a suspected urethrocutaneous fistula was noted on the right side of the root of the penis and a neglected malaligned fracture of the left femur ().\nA clinical diagnosis of vesicointestinal and urethrocutaneous fistulae with urosepsis in a patient with malunion of the left femoral fracture was made.\nThe admitting packed cell volume was 20% with leucocytosis of 20.6 × 109/L and neutrophil of 75%. The platelet was adequate. The blood biochemistry revealed urea of 16 mmol/L but other parameters were within normal limits. Urinalysis and urine culture could not be done for lack of sample. The blood culture yielded no bacteria growth after 48-hour incubation. The abdominopelvic ultrasound showed mild fullness of the collecting system of the right kidney and nonvisualisation of the bladder.\nHe was optimised by correction of the fluid deficit. He had a combination of parenteral antibiotic therapy (ciprofloxacin, metronidazole, and gentamicin)and three pints of blood transfused.\nHe subsequently had micturating cystourethrography which confirmed the fistulous connection with the sigmoid colon ().\nHe consented for exploratory laparotomy and closure of the fistula which he had as a single stage procedure, without colostomy, after an initial bowel preparation. The intraoperative findings were those of fistulous connection with a diameter of 3.5 cm, between the fundus of the bladder and antimesenteric border of the sigmoid colon and minimal inflammatory adhesions in the pelvis. There was no evidence of colonic diverticulitis (Figures and ). The fistulous connection was incised and the edges excised and freshened; the bladder was closed in two layers and extraperitonealised while the sigmoid was closed in single layer with interrupted vicryl 2/0 suture. The two ureters were stented with paediatric feeding tube (size 8) and brought out through a separate stab wound. A suprapubic cystostomy tube was left in place to protect the urethrocutaneous fistula. He did well postoperatively except for the superficial wound infection that he developed. The loose stool stopped and the cystostomy tube was draining urine before discharge. He later had repair of the urethrocutaneous fistula, which healed well. He was discharged for orthopaedic followup at the outpatient clinic.
A 38-year-old female patient came with a chief complaint of difficulty standing up from squatting position since 2 years ago. The patient also suffered heaviness and numbness from her hips that radiated to both of her knees and ankles. The symptoms worsened steadily in the past 4 months with both lower limbs getting weaker. Laboratory results came out normal, with no signs of infection or positive tumor markers. Radiological examination showed no apparent abnormalities as well. An MRI was obtained, and a tumor mass in the intradural region level of T10–T12 was found (). At that time, the patient was offered surgery, but she chose to undergo treatment with a bone setter. Around two months later, the patient returned to hospital with profound weakness on her lower extremity. Her physical examination revealed paresis from her thigh on both lower extremities grade 1-2/5 power in left and right lower limbs, respectively. Increased patellar reflexes were found on both limbs. Another MRI was performed and showed that the mass had grown to lumbar vertebrae L2, accompanied with worsening of the neurological statuses and impaired sensibility, as well as defecating and urinating problems (). From the history, spinal manipulation procedure was performed by a bone setter, although no specific techniques were available for review.\nA surgical procedure was proposed for exploration and decompression to the patient. The operation started by opening the lamina on T10–T12 levels, followed with laminectomy and hemostatic procedure to stop the bleeding, until the dura was exposed (). A dense mass from T10 to T12 was palpable from the dura layer. After we exposed the lamina, we observed that the dura was tense from touch, and a solid mass underneath the dura was palpable from T10 to L2. Intradural tumor excision was performed by a sharp 3 mm incision in the midline of the dura and then continued with blunt dissection, opening the dura layer to caudal L2 and to cranial T10. Dura was then parted with stay thread until the vessel-rich tumor mass was exposed. The tumor mass was excised, and the surgical field was contaminated by blood from hematomas from tumor vessels (). Bleeding was found to originate from the anterior part and posterior part of the cord, no bleeding source from the cerebrospinal fluid nor the subarachnoid space. The tumor mass was successfully evacuated with fragments of hematomas and necrotic tissues. The dura layer was then closed with a continuous suture. The tumor mass was fixed and transported for histopathology examination ().\nAt the time of discharge, the patient did not regain the function on her lower extremities (1-2 out of 5 on neurological motor examination). After six months of follow-up, some improvement on her lower extremity function was noted. Motor strength was returned to 3-4 out of 5, and the patient was able to ambulate using a walker. No improvement of her bowel and bladder symptoms was noted.
A 39-year-old woman was scheduled to undergo split thickness skin grafts as part of a reconstructive program following extensive burns. She was burned in a house fire 2 years previously, when she suffered 93% total body surface area burns, with a burn index of 85. Her history was significant for having undergone 39 reconstructive operations over 2 years. Her neck was reconstructed using a graft from the latissimus dorsi, and both femoral veins were occluded due to multiple accesses and indwelling catheters. A subclavian venous catheter had been inserted once before under ultrasound guidance. Physical exam showed her weight was 49 kg, and her height was 155 cm. Most of her body was covered by hard contracted skin. There were no peripheral veins evident on inspection.\nTo obtain venous access for this operation, we searched for veins using a linear probe ultrasound device (6–15 MHz, SonoSite Edge, FUJIFILM SonoSite, Inc., Washington, USA) on the chest and arm. This revealed accessible veins, including the subclavian and axillary veins on the anterior chest, and the brachial vein of the right arm. An indwelling catheter in the right brachial vein was considered as the first choice to avoid possible complications of using the subclavian or axillary veins such as pneumothorax or hemothorax. The right brachial vein measured 3 mm by ultrasound imaging.\nThe right arm had restricted motion range due to extensive contractures. She was positioned in the right semilateral position to gain easy access to the medial side of the arm by supination and abduction. A pillow was placed behind her back to maintain this position. The skin of the arm was prepped with 1% chlorhexidine alcohol solution and covered with a sterile drape. The ultrasound probe was covered with a sterile plastic probe cover. The indwelling venous catheter was placed using sterile barrier precautions. Local anesthetic (5 mL of 1% lidocaine) was injected, and a 20G catheter-over-the needle (48 mm) was inserted. Ultrasound-guided venous catheterization was performed. To access the brachial vein, we used the short-axis out-of-plane approach to avoid mechanical complications of unanticipated artery or peripheral nerve injuries, and then used the long-axis in-plane approach to penetrate the anterior vein wall and cannulate the vein. After inserting the cannula, a guide wire was placed through the cannula using the modified Seldinger technique. We placed a single lumen polyurethane catheter (3 Fr., SMAC Plus, Nippon Covidien, Japan), a commercially available central venous catheter (there is no commercially available midline catheter in Japan). Successful insertion of the catheter was confirmed with ultrasound imaging (Fig. ). The catheter entered the vein 6 cm from the skin entry site (Fig. ). After placing the catheter, we checked venous flow using color Doppler imaging (Fig. ).\nSurgery was performed the following day with no adverse events. A split-thickness skin graft was harvested from the head, and grafted to the neck. The skin graft became infected several days later and the midline catheter was used for administration of antibiotics. A second skin graft was performed again postadmission day 16 and the catheter removed on postadmission day 24. She was discharged without complications.
A 31-year-old obese female presented with a 6-month history of intermittent pelvic pain along with occasional right lower extremity paresthesias. Her only significant medical history was that at birth she was found to have a congenital sacrococcygeal teratoma (). She underwent surgery for this at birth and subsequently developed normally without deficit. Now, at 31 years of age, she presented with the above symptoms. Physical exam revealed a well-healed surgical scar on her right buttock. She had no motor deficits and no abnormality on rectal or vaginal exam. CT of the abdomen and pelvis revealed a cystic mass in the retrorectal space. MRI was done to further characterize the lesion and this showed a 6.0 × 5.8 cm cystic mass in the retrorectal space extending from the coccyx across midline into the region of the right piriformis and acetabulum and it was deep to the right gluteal musculature (). Anoscopy and flexible proctoscopy revealed no disruption of the mucosa or other abnormalities anywhere. Surgical resection was recommended and informed consent was obtained.\nThe mass was approached operatively with the patient in prone position and through a parasacrococcygeal incision. It was found to be a well-encapsulated cystic lesion and it was completely resected en block with the coccyx. Histologic sections demonstrated an invasive mucinous adenocarcinoma with pools of mucin and moderately to well-differentiated malignant glands coming to within 1 mm of the resected margin. The tumor cells showed immunoreactivity to CDX2, a marker of intestinal differentiation, and coexpression of keratins CK20 and CK7. Smaller areas of teratoma were also identified and consisted of a pancreatic parenchyma, salivary gland tissue, and gut wall. The gut wall was composed of intestinal type mucosa with an underlying layer of smooth muscle resembling muscularis mucosa. These findings are consistent with a teratoma demonstrating endodermal and mesodermal components (). Because of these findings and a close surgical margin at the lateral extent of the mass, adjuvant chemoradiation therapy was subsequently recommended.
An 18 year old female presented to the clinic with a 4 month history of pain and swelling in the right foot. The patient had no history of trauma and denied any recent history of fevers and chills. Pain was insidious in onset and gradually worsened causing difficulty in walking. Pain had increased markedly during the two months prior to presentation to our clinic. The patient had a liver abscess at the age of 4 and past open heart surgery for total correction of tetralogy of fallot at the age of 7 years. On examination the patient had tenderness and a swelling on the outer aspect of the right foot in the calcanocuboid region. There was no soft tissue involvement even though the overlying skin was warm. No appreciable lymphadenopathy was noted. She could not bear weight on the right foot. Motor function was difficult to asses due to excruciating pain on movement; she would drag her foot on the ground while walking suggesting that dorsiflexion was severely affected.\nConventional radiographs showed a lytic lucent area within the right cuboid bone (Figure &). Septations were seen, but the cortex was intact. No fractures or dislocation of the cuboid was noted.\nMRI showed cystic areas with fluid filled levels in the right cuboid bone (Figure ). Mild expansion of the bone was noted. However no cortical break or involvement of other tarsal bones was seen. The lesion appeared hypointense on T1 and hyperintense on T2 images and also showed post contrast enhancement. Based on the imaging studies the foremost differential diagnosis of giant cell tumor, chondroblastoma, and aneurysmal bone cyst were made.\nAn open biopsy was thereafter performed. Microscopic examination of the tissue revealed sheets of cells exhibiting oval to elongated nuclei and moderate eosinophilic cytoplasm with distinct highlighted cell boundaries. Cells were indented with lobulated nuclei (Figure ). Occasional mitotic figures and scattered giant cells were also identified. Focal areas of fine calcification around individual cells (called chicken wire calcification) were seen (Figure ). Tumor cells were positive for glycogen on PAS stain. Cells were set in chondroid matrix which was highlighted with PAS stain (Figure ). In some areas cystic spaces containing hemorrhage along with multinucleated giant cells in the wall were also seen. A diagnosis of chondroblastoma associated with an aneurysmal bone cyst was made.\nAn intralesional curettage using a high speed burr was then performed. The defect was then filled in by cancellous bone graft and bone substitutes.\nAt 6 months post-operatively the patient was ambulating normally without a limp. Range of motion at the ankle, subtalar, and midtarsal joints had improved significantly. The patient will be followed with serial radiographs at 3-months for 1 year. Thereafter, radiographs will be obtained every 6 months and then yearly until 5 years post-operatively. Her recent radiograph shows good incorporation of the bone graft.
Our patient is a 70-year-old male with a past medical history of GERD and hypertension who complaint of fatigue, bright red blood per rectum, weight loss and poor appetite for 1 day. Previous colonoscopies were significant for internal hemorrhoids.\nA surgical consult was called on hospital day #1 when the patient was noted to have a small bowel obstruction on CT. A nasogastric tube was placed. Hematology was consulted secondary to proteinemia and an M spike on the laboratory work. A diagnosis of multiple myeloma was entertained. He underwent a bone marrow biopsy, which confirmed the diagnosis.\nA repeat CT Abd/Pelvis was performed given the lack of improvement. This showed worsening dilatation of small bowel loops and a transition point in the distal ileum with thickening and mesenteric edema, and it was decided that the patient should be taken to the operating room (OR).\nThe patient underwent an exploratory laparotomy. No obvious transition points were observed. The small bowel appeared friable and hemorrhagic. Two enterotomies were made and the patient started bleeding profusely from within the lumen (EBL 2L). Intraoperative EGD revealed diffuse mucosal sloughing and bleeding from the duodenal mucosa. Patient's abdomen was closed with a temporary abdominal closure device.\nSubsequent take-backs to the OR revealed improvement and subsequently the abdomen was closed. A biopsy taken from the stomach and duodenal mucosa showed amyloid deposition in the lamina propria and submucosal tissue of duodenum consistent with amyloidosis. He was started on high-dose steroids. Nasogastric tube decompression was continued. Despite declining IgG levels, he remained with an unresolving ileus. Following an extensive family discussion regarding the risks and benefits of any procedure, he underwent an open venting gastrostomy tube placement in hope for discharge to hospice.\nDuring this operative procedure, dilated loops of small bowel and multiple serosal tears were again noted. Our patient did not show much improvement from his previous operations, which were well over a month ago. At the conclusion of the case, sanguinous drainage was noted from the gastrostomy tube. The patient continued to decline clinically following the gastrostomy tube placement and eventually expired.
A 53-year-old Caucasian woman was hospitalised on the 10 October 2016, reporting abdominal pain that had been constant for 4 days prior to hospitalisation and exacerbated by physical activity. The patient had been on APD since 2014 due to end-stage renal disease and autosomal dominant polycystic kidney disease and was on a waiting list for kidney transplantation. The patient had never experienced dialysis-related infections or other complications before the hospitalisation described in this report.\nThe patient had a prior history of hypertension and psoriasis, but no history of liver cirrhosis.\nIn April 2016, the patient was hospitalised with pyelonephritis and was treated with intravenous cefuroxime. She was also treated empirically with intraperitoneal gentamicin (80 mg) and vancomycin (2 g), because peritonitis could not be excluded at the time of admission. Peritoneal fluid was collected and did not show any growth, therefore the intraperitoneal antibiotics were discontinued. The cause of the infection was not determined, but it was likely related to an infected cyst in her kidney. On the 12 April, the patient was discharged with oral ciprofloxacin.\nFive months later, on the 10 October 2016, the patient was hospitalised reporting of constant abdominal pain for 4 days prior to hospitalisation. She had a 39.4°C fever, nausea and had vomited once. Her vital signs were blood pressure of 152/87 mm Hg, heart rate of 78 beats per minute and 96% oxygen saturation without supplementation.\nThe peritoneal fluid was cloudy and turbid and a urine test strip was positive for leucocytes. These findings raised the suspicion of peritonitis and prompted the clinician to send the peritoneal fluid for microbiological examinations. The patient’s dry body weight was 87.5 kg. At admission, the weight was 89.2 kg. The patient was treated empirically with vancomycin (2 g) and gentamicin (80 mg) intraperitoneally as in the previous hospitalisation. The patient was also treated empirically with intravenous cefuroxime 1.5 g daily and metronidazole 500 mg three times a day.\nThe blood cultures were negative. On 11th of October, the culturing results from the peritoneal fluid showed growth of L. monocytogenes. The patient previously had a reported assumed allergic reaction to penicillin from back in her childhood; the correct treatment was not started right away on the day of the positive cultures with L. monocytogenes. On 12 October, the patient was successfully started without any allergic reaction on an oral amoxicillin course of 1 g three times a day for 14 days. The reason for not starting the right treatment right away was that the hospital staff wanted to be prepared with anaphylaxis treatment, if the patient was to react to the amoxicillin treatment. Intraperitoneal gentamicin and vancomycin and intravenous cefuroxime and metronidazole were discontinued. The dialysis catheter was not displaced and was determined to still be functional.\nFour days later, on 14 October, the patient was discharged with no abdominal pain and her peritoneal fluid was transparent without any sign of infection. The peritoneal fluid was cultured and was found without any growth. The urine test strip was negative for leucocytes and nitrites. She was seen again in the outpatient clinic where she was treated with intraperitoneal vancomycin (2 g) once a week for 3 weeks.\nThe National Danish Reference Laboratory for Clinical Microbiology (Statens Serum Institute in Copenhagen, Denmark) reported the isolate to be an L. monocytogenes serotype 1/2a and Multilocus Sequence typing (MLST) type ST91.
A 73-year-old white man presented to our emergency department with a 3-day history of left lower extremity swelling and acute-onset shortness of breath. On evaluation, he was tachycardic with a pulse of 113, hypertensive with a systolic blood pressure of 130-170 mmHg, and demonstrated poor oxygen saturation of 81% on room air. He was supported with continuous positive airway pressure (CPAP) and supplemental oxygen while a computed tomography angiogram (CTA) was obtained, which revealed a saddle PE (Fig. ).\nTissue plasminogen activator (tPA) was administered and he was started on a heparin infusion and admitted to our intensive care unit (ICU) for management. He remained on the heparin infusion for 3 days, during which he continuously improved and was eventually weaned to 3 L oxygen via nasal cannula. On hospital day 2, he was transferred to intermediate level of care. Per hematology recommendations, he would have to be on indefinite anticoagulation due to the massive PE he had sustained, the source of which was a left lower extremity popliteal deep vein thrombosis (DVT). The plan was to transition him from the heparin infusion to enoxaparin twice per day with hematology follow-up in 1 month.\nOn the day of discharge, however, he had sudden onset of right leg numbness and weakness below the level of his hip. He had previously been working with physical therapy and had been able to walk 200 feet with the assistance of a walker during each session. A physical examination revealed decreased sensation to light touch, 2/5 strength in right hip flexion and right knee extension and flexion, and loss of right patellar reflex. Left leg physical examination was normal at that time.\nAn emergent head computed tomography (CT) scan was ordered due to concern for a possible stroke, and neurology was consulted. The head CT was negative for infarction or hemorrhage. Neurology was concerned for spinal cord infarction versus hematoma and recommended emergent magnetic resonance imaging (MRI) of his thoracic and lumbar spine. The MRI revealed a left psoas hematoma (Fig. ). A CT of his pelvis performed the same day also showed a right psoas and iliacus hematoma. Due to these findings, hematology recommended discontinuing enoxaparin and reverting to a low intensity heparin infusion, as well as placement of an inferior vena cava (IVC) filter. The following day his left leg began exhibiting the same symptoms as his right leg. There was concern regarding the risk of progressive and irreversible nerve damage due to compression if the hematomas were not promptly drained. IR was consulted and advised that if the drainage were to occur while our patient was on anticoagulation, the risk of rebleeding into the retroperitoneum would be high and potentially nullify any benefit from drainage. Our patient would also be at risk of hemodynamic instability if the current hematomas were acting as tamponades against further bleeding. An additional complicating factor was the risk of further thrombosis due to the presenting saddle PE. Hematology was consulted for recommendations on pausing anticoagulation, but they were hesitant to offer a timeframe as there was no established safe period to enable this type of procedure to take place. Eventually, a window period of pausing the heparin infusion for 3 hours pre-procedure and up to 6 hours post-procedure was decided upon in the event that our patient agreed to have the drainage performed.\nThroughout this sequence of events, our patient and his wife were aware of the plans and considerations on how to proceed. They were informed of the recommendations and concerns made by neurology, hematology, and IR, as well as the risks and benefits of intervention versus non-intervention.\nAfter speaking with his wife, our patient decided to undergo the procedure. The low intensity heparin infusion was stopped 3 hours beforehand and the IR team then performed drainage of the right retroperitoneal hematoma, placing two pigtail catheters in our patient’s right flank (Fig. ). In total, the hematoma was drained of 215 milliliters of blood, 10 milliliters of which were drained during the procedure itself. The left psoas hematoma was not found to be amenable to drainage.\nOur patient tolerated the procedure well, and the heparin infusion was restarted 6 hours after it was completed. A repeat neurological examination demonstrated improved lower extremity strength bilaterally as well as the return of sensation to light touch. Hip flexion improved to 3/5 bilaterally, and knee flexion and extension improved to 4/5 bilaterally. Deep tendon reflexes remained absent. Four days later, the pigtail catheters were removed. His recovery was complicated by anemia requiring blood transfusions totaling 4 units of packed red blood cells (PRBC). Other sources of potential bleeding were evaluated and not found. A repeat CT on hospital day 10 (Fig. ) showed a stable right-sided hematoma, and our patient did not experience any further neurologic deficits. He was transitioned again from the heparin infusion to enoxaparin after 3 more days. His hemoglobin and hematocrit remained stable. During this time, he worked with physical therapy, who recommended discharge to a skilled nursing facility where his strength began to improve somewhat. Follow-up was scheduled with neurology and hematology. On hospital day 18, he was safely discharged.
A 75-year-old man presented with a 2-day history of nonbilious vomiting without abdominal pain. He received a deceased donor kidney transplant in 2010 for end-stage kidney disease secondary to autosomal dominant polycystic kidney disease. His postoperative course had been uncomplicated, and his kidney function had been stable on standard immunosuppressive therapy with prednisone, cyclosporine, and mycophenolate mofetil with a serum creatinine of 150 µmol/L. His history was significant for a myocardial infarction requiring coronary artery bypass and sciatica. Two years prior to kidney transplantation, he had a left nephrectomy for a kidney mass, which was benign, complicated by a ventral hernia requiring repair. Six weeks prior to presentation, his creatinine rose to 200 µmol/L. One week prior to admission, his creatinine rose to 280 µmol/L and an ultrasound of his transplant kidney revealed mild hydronephrosis and the entire length of the ureter was not visualized ( and ).\nHis physical examination revealed a nonobese man without any abdominal tenderness to palpation and no evidence of hernia, as assessed by the nephrology and urology teams. Investigations revealed a serum creatinine of 370 µmol/L. Urinalysis was negative for blood and protein. Electrocardiography (EKG) did not reveal any changes compared with 1 year prior, and 2 serial troponin I values were unremarkable at was 26 and 27 ηg/L, respectively. Abdominal ultrasound revealed mild hydroureteronephrosis of the transplant kidney in the right iliac fossa, with tapered dilation of the ureter. The distal ureter was obscured by overlying bowel gas and not seen (). Abdominal computed tomography revealed moderate hydronephrosis of the transplant kidney due to obstructed herniation of the transplant ureter in a right inguinal hernia ( and ). An antegrade double-J stent was percutaneously inserted into the transplant ureter at the level of the obstruction to identify and preserve the transplant ureter at the time of inguinal hernia repair. He subsequently underwent a successful open right inguinal hernia repair with polypropylene mesh reinforcement. The transplant ureter with indwelling stent was palpable within the hernia sac and not felt to be excessive in length, so it was not reimplanted. His creatinine returned to baseline at the time of hospital discharge. Three weeks later, repeat Doppler ultrasound of the transplant kidney showed resolution of the hydronephrosis and his ureteral stent was removed.
A 15-year-old female with no significant past medical history presented after being struck in the face by a ball while playing water polo. The patient felt pain in her jaw, which was the chief complaint when she presented to the emergency department. Upon neurological assessment, the patient complained of midline tenderness from the skull base to midline cervical spine over C3; denied headaches, changes in vision, speech or swallowing, extremity weakness or paresthesias. A maxillofacial computed tomography (CT) scan did not show evidence of an acute facial fracture. However, the CT scan did reveal a radiolucent, ovoid-shaped lytic lesion arising in the left lateral mass of C1, between the anterior tubercle and the transverse process. Magnetic resonance imaging (MRI) studies further confirmed an enhancing osseous lesion at the left lateral mass of C1, with cortical breach and extension into the left lateral atlantodental joint space (). Of note, three years prior, patient had a CT cervical spine which, upon retrospective review, demonstrated a similar but much smaller lesion.\nDifferential diagnoses underlying this vertebral cortical erosion included those of infectious etiology, as well as oncologic lesions, such as giant cell tumor of bone, aneurysmal bone cyst, osteoblastoma, osteosarcoma or even Langerhans histiocytosis (LCH). Oncology recommended that the cervical spine lesion be biopsied for tissue diagnosis. Due to the unusual location of the lesion and risk of locally aggressive pathology, or possible tumor seeding along the biopsy track, interventional radiology was unable to perform a CT guided needle biopsy. It was therefore decided that the patient would require open neurosurgical biopsy for diagnosis.\nDue to the anterior and lateral location of the vertebral lesion, an anterior transoral approach to the C1 lesion was performed, in order to obtain a sufficient amount of the contrast enhancing component of the mass for pathologic diagnosis. The transoral approach was performed in a multidisciplinary fashion, during which the otolaryngology team used direct visualization, as well as stereotactic navigation, to expose the C1 anterior tubercle on the left side. Once exposure was completed, neurosurgery team utilized a matchstick burr to then drill the anterior outer cortex of C1. Multiple specimens from the fibrous tumor were taken, with curettes and pituitary forceps.\nThe sampled tissue did not show features of osteoblastoma or osteosarcoma, nor were there features of LCH or signs of infection. In the sampled region, the lesion consisted of a proliferation of nondescript stromal cells with intermixed multinucleated giant cells, and occasional clusters of foamy histiocytes (). Special testing for giant cell tumor of bone (G34W staining) was negative, as was fluorescence in situ hybridization (FISH) testing for Ubiquitin Specific Peptidase 6 (USP6), making a primary form of aneurysmal bone cyst unlikely. However, due to the aggressive nature of the patient’s osteolytic lesion and the significant risk for atlantoaxial instability associated with its location, it was decided to start the patient on Denosumab. Denosumab is an osteoclast inhibiting pharmaceutical agent, which was administered to the patient in order to stabilize and consolidate the lesion. Samples of the patient’s lesion were also sent out to a nationally recognized expert bone pathologist, whose findings were most consistent with benign giant cell rich lesion with histiocytes.\nThe patient was re-assessed three months postoperatively and MRI studies revealed that there was no interval decrease in the size of the tumor. In fact, there was a slight progression of the lesion anteriorly, despite treatment with Denosumab. After presenting the patient’s case at our institution’s multidisciplinary tumor board, it was decided to offer the patient a gross total resection of the offending lesion. This would inherently lead to significant atlantoaxial instability, therefore a posterior occiput to cervical three instrumented fusion was also warranted.\nThe transoral approach was performed in a multidisciplinary fashion, during which the otolaryngology team used direct visualization as well as stereotactic navigation, to expose the cervical vertebrae through the posterior pharynx. Fibrous tumor was identified and dissected until superior, inferior, and lateral margins of tumor resection were confirmed grossly, with fluoroscopy, and neuronavigation. Additional C1 anterior tubercle eccentric towards the right side was also taken, to include a normal bony margin. A small rim of tumor adherent to the vertebral artery was left behind. After the otolaryngology team closed the posterior pharynx, the patient was carefully turned prone, maintaining spinal precautions. Base of the occiput to cervical three was then exposed. C2 pedicle screws were placed. C3 lateral mass screws were placed. An occipital plate was sized. Screws into the occiput were placed. Fluoroscopy confirmed excellent position and spinal alignment. There were no post-operative complications and the patient was discharged home in good condition. Pathologic examination of the resected material at this time showed complete disappearance of the giant cells, due to Denosumab therapy, with the remaining lesional tissue resembling benign fibrous histiocytoma (). Post-operative imaging studies revealed a stable posterior cervical spine construct, along with minimal rim-enhancement along the vertebral artery, as expected (). At a three-week follow up visit in clinic, the patient’s incisions were healing well, she was neurologically intact, tolerating regular diet, and was eager to return to school.
A 58-year-old Chinese man visited our department complaining of intermittent blood-stained posterior nasal discharge for six months and a three-week episode of fitful light headaches, which occurred five years ago. The patient reported normal nasal ventilation, olfactory sensation, and facial sensation. He had no ophthalmological complaints. Physical examination showed a polypoid mass in the left middle nasal meatus and a papillary mass in the right posterior olfactory cleft. No enlargement of the cervical lymph nodes was discovered. Coronal computed tomography (CT) scans of the sinuses demonstrated soft masses in the posterior ethmoid sinuses and bilateral sphenoid sinuses with bone absorption (). Tissue biopsy under nasal endoscopy indicated that the left polypoid mass was a nasal polyp while the right papillary mass was an inverted papilloma.\nThe patient underwent bilateral functional endoscopic sinus surgery and resection of the right nasal inverted papilloma. Intraoperatively, a polypoid mass was found in the left middle nasal meatus. There was mucus present in the posterior right and left ethmoid sinuses. No mass was discovered in the ethmoid sinuses; rather, only edema was present. Absence of tumor cells was confirmed by pathology. Papillary masses in bilateral sphenoid sinuses were also found. Radical excision of the papillary masses was performed. The mucosa of the sphenoid sinuses was also removed, while the sella turcica and lateral walls were kept intact.\nPathologic examination with light microscopy revealed that the mass in the left sphenoid sinus actually consisted of two distinct parts. In one part, atypical proliferating epithelial cells arranged like irregular glands (adenocarcinoma-like) distributed among a fibrous substance were observed (). In the second, papillary hyperplasia of the transitional epithelium was discovered (). The mass in the right sphenoid sinus was also characterized by papillary hyperplasia of the transitional epithelium. The septum dividing the right and left sphenoid sinuses was intact, and there was no communication between the right and left masses; thus, we considered them to be separate entities. Immunohistochemical evaluation of the first part revealed positive staining for Vimentin and CD99 (, insert) and positive staining focally for CK. It was negative for CD31 and Bcl-2. Three experienced pathologists independently made the final pathologic diagnosis of MESS accompanied by an inverted papilloma. Accordingly, the patient underwent adjuvant radiotherapy and subsequent chemotherapy beginning three weeks after surgery. At the 50-month follow-up visit, there were no signs of recurrence.
A 57 year old male had previously undergone a left total knee arthroplasty in 1999 for osteoarthritis. He acquired a late deep peri-prosthetic infection with a multi-resistant Staphylococcus epidermidis. The organism was sensitive to vancomycin and rifampicin. A two stage revision was undertaken after clinical signs of infection had resolved and blood parameters had normalized. Intra-operative gram stain was negative for microorganisms and frozen section of deep tissue was less than five polymorphs per high power field [-].\nA cemented S-ROM prosthesis was implanted using a coronal tibial osteotomy and a lateral release for exposure [,].\nThe primary surgeon followed all the guidelines as described in the instructional booklet for the S-ROM implant. A cemented SROM modular tibial plate plus tibial sleeve and an uncemented 15 x 100 mm press fit tibial stem extension was inserted. The femoral side comprised of a cemented Noiles rotating hinge component, a cemented 46 mm S-ROM femoral sleeve which was matched with an uncemented 17 x 150 mm press fit femoral extension. The implant reconstruction was completed using a 12 mm small SROM Noiles rotating hinge polyethylene and axle inserted from the medial side. The patella was not resurfaced secondary to marked bone deficiency.\nLong term antibiotics were prescribed and follow up at regular intervals for the next eight months revealed that all of the patient’s blood parameters; erthrocyte sedimentation rate (ESR), C-reactive protein (CRP) and white cell count (WCC) were within normal limits. Radiographically the knee was unremarkable. The patient carried out normal activities of daily living. The patient presented three years following the second stage of revision after reportedly falling on a wet floor six weeks previously. Prior to the fall, the patient did not require any analgesia and reported normal function with activities of daily living and clinically had a range of motion from zero to one hundred and five degrees. After the fall, the patient’s function became increasingly impaired and required crutches for assisted ambulation, which was limited to less than fifty meters. He was required to climb stairs one at a time with a railing and required assisted transfers. Clinically, his height was 173.5 cm and weight 140 kilograms, exhibited an antalgic gait, a well healed surgical scar, an effusion and tenderness around the pes anserinus. The knee had a range of motion of zero to one hundred degrees and quadriceps power was grade four.\nRadiographically, there was a broken tibial wire, osteolysis and pedestal formation around both the femoral and distal tibial stem extensions. The prosthesis was bent at the proximal tibial sleeve and stem junction. The ESR and CRP were 17 and 16.7, respectively. A bone scan showed moderate uptake around the prosthesis, especially the proximal medial tibia and the patella. Labelled white cell scan exhibited stress remodelling and synovitis but was not consistent with infection []. There was no catastrophic bone loss around the failed modular junction as it is known that revision modular femoral components can fail if the modular junction is unprotected/unsupported.\nThe prosthesis was considered loose with mechanical failure. Due to the morbid obesity of the patient, he was referred for laparoscopic gastric banding to facilitate weight loss prior to his revision total knee arthroplasty. Once his weight had decreased to approximately 120 kilograms the revision knee procedure was undertaken. Increasing morbid obesity, and with body mass index (BMI) increasing over the years, bariatric surgery has been well proven in the past few years in treating obesity.\nExposure was through the previous incision and once again a coronal tibial tubercle osteotomy was undertaken. The pseudo capsule sample of frozen section revealed less than five white cells per high power field, excluding active infection. There was marked metallosis with loosening of both the femoral and tibial components at the cement-bone interface. At implant removal it was noted that the femoral and tibial components at the modular metaphyseal sleeve-stem junction were fractured.\nExtensive debridement was carried out on both the tibial and femoral sides. The host bone was deficient with Engh type 3 defects in both the distal femur and proximal tibia [--]. The uncontained defects were reconstructed using anatomic specific structural and morcellised impaction allograft. Another S-ROM modular revision stemmed implant was cemented into position ().
A 34-year-old woman with a diagnosis of PH for 4 years was referred to headache clinic for preconception counseling. She had about 7 to 15 headache episodes per day, and her headaches are characterized by a unilateral, moderate to severe, occasionally nausea, and photophobia, localized to left orbital, supraorbital, and occipital areas, sharp and throbbing pain radiating to same side neck and shoulder, accompanied by ipsilateral autonomic features such as eyelid edema, ptosis, lacrimation, and nasal congestion and/or rhinorrhea lasting 5 to 15 minutes. Those headaches typically responded well to indomethacin. She was being treated with indomethacin 25 mg 3 times a day and lansoprazole 15 mg once a day (proton pump inhibitor). The numeric rating scale (NRS) score was 8 to 9 out of 10. She did not have a history of headache trauma and nocturnal headaches. She reported that when she stopped using indomethacin, her headache attacks recurred. She had normal neurological examination, blood, urine, and coagulation tests. She complained of some tenderness to palpation over the left temple, occipital and neck sites, and regional pain sensitivity was described by noxious pressure. Contrast enhanced magnetic resonance (MR) imaging of the brain and MR angiography were both normal. The patient met the ICHD-3 diagnostic criteria for chronic PH. She reported that she wanted to try to conceive within the next few months. Interventional pain management by performing repetitive peripheral cranial nerve and SPG blocks was planned. Informed consent for publication has been obtained from the patient.\nThe patient gave her consent for interventional pain treatment. Change of pain severity in the NRS was used to assess the response to nerve blocks. The patient stopped taking indomethacin during the procedures. At first, a mixture of local anesthetic 4 mL of 2% lidocaine and 1 mL of methylprednisolone acetate was injected at the left great occipital nerve (GON) located at approximately 10 mm medial to the midpoint of the line of the occipital tubercle and the mastoid tip. Mild pain relief effect had been presented within the first week. In addition to GON block, left infraorbital and supraorbital nerve (SON) blocks with 1 mL of 2% lidocaine were performed once a week for 2 weeks. However, the number of attacks and pain severity were not improved after 3 weeks. SPGB was performed with sterile cotton sticks, soaked in 10% lidocaine, inserted through the patient's nose to the back of nasopharynx for 30 minutes, once a week for 3 weeks. Pain frequency and severity were not significantly changed. The degree of pain remained at NRS 8 to 9 at 6 weeks after the first injection. She was continued on treatment with indomethacin. No adverse effects of the procedures were reported.\nA follow-up of 3 months showed that there was no pain relief following the injections and patient was needed to be maintained on indomethacin.
A 16-month-old boy developed a painless swelling of his right knee after a fall to the ground. He was brought to his local hospital, where a knee radiograph was performed, which did not disclose any abnormality. A diagnosis of traumatic arthropathy was made. A few days of weight-bearing avoidance and ice-pack application led to quick reduction of joint swelling, which, however, did not resolve completely. Indeed, over the following months the right knee always appeared to the parents slightly more swollen than the contralateral. Moreover, recurrent exacerbation of swelling, often following a minor trauma, was noted. One year after the onset of symptoms, the child was hospitalized elsewhere to investigate the cause of persistent right knee swelling. All laboratory tests, including acute phase reactants, antinuclear antibodies, and rheumatoid factor, and a further plain radiograph were negative. A diagnosis of JIA was made and nonsteroidal anti-inflammatory (NSAID) therapy with ibuprofen was prescribed, which had no appreciable effect. The boy was seen at the outpatient clinic of our unit at the age of 3 years, shortly after a further episode of knee swelling, preceded by a mild local trauma. On clinical examination, the right knee appeared swollen, but was modestly tender and painful on passive motion; considerable joint effusion and slight restriction of flexion were detectable. The remaining joints and the general physical findings were within normal limits. Knee ultrasonography revealed a bulk of hyperechogeneic material in the supra-patellar region, suggesting prominent synovial hypertrophy, and marked effusion. Since there was a discrepancy between the clinical and ultrasonographic findings potentially consistent with JIA and the history of a close relationship between the exacerbation of joint swelling and previous trauma, an arthrocentesis was performed. Aspiration led to evacuate 20 ml of bloody fluid. To rule out a bleeding disorder, the clotting tests were requested, which yielded normal results. An MRI of the knee was, then, performed, which demonstrated an extensive lesion, with low signal in T1-weighted images and high signal in T2-weigthed and stir images, nearly occupying the entire synovial cavity, and a large fluid collection (Fig. ). A diagnostic arthroscopy led to the histopathological diagnosis of IAVM (Fig. ). One week later, the lesion was resected surgically. At 3 months after surgery, the right knee did not show any evidence of swelling or fluid.
We report the case of a 67-year-old woman with a medical history of nontoxic goiter, dyslipidemia and depressive syndrome, medicated with simvastatine 20 mg daily and alprazolam 0.5 mg daily. She had been medicated in the past with sertraline 50 mg daily, but decide to stop the previous year, due to the fact that she felt much better. However, due to increased anhedonia and anxiety in the previous month, she was advised to resume sertraline, which she did in the previous two weeks.\nUpon a scheduled medical appointment, she referred that in the previous week she had had episodes of abnormal bodily perceptions. She felt that her hands somehow enlarged or diminished, although she knew that was not possible and when looking they appeared perfectly normal. During these episodes she sometimes felt that her body levitated towards the ceiling. Another time she felt that her whole body grew gigantic and in three occasions she felt instead that she had diminished, as if shrunk by an outside force. Associated to these episodes, the patient reported that some objects (wardrobe, lamp, chair) reduced in size and seemed strangely far away. These episodes lasted only a few minutes and recurred at any given time of day or night. She had insight during the occurrence of all the episodes, referring that she knew what she was describing was just a feeling and that it would be impossible for these alterations to actually occur. She also denied increased anxiety, a sense of detachment, or a feeling of being outside herself during these episodes. Two days previously she was observed by an ophthalmologist and complained about these episodes. Her visual examination showed no alterations from normal standards, and she was advised to consult her attending physician.\nA thorough physical examination revealed no alterations and the neurological examination was unremarkable. She was oriented to a revaluation appointment within a month and to pursue investigation a cerebral computerized axial tomography (cerebral CAT) and blood tests (complete hemogram, sodium and potassium concentrations, creatinine and urea, thyroid stimulating hormone, tetraiodotironine and triiodothyronine) were scheduled.\nOne month later she reported that the episodes of abnormal bodily and external perceptions had ceased within a week. She was feeling better from her anhedonia and anxiety and recognized that these improvements were associated with sertraline. However, she remembered that in the first weeks after taking sertraline for the first time, almost ten years ago, she had experienced similar episodes of abnormal bodily sensations, having the sense that she grew or shrunk or even that she levitated. Her blood chemistry, besides a low thyroid stimulating hormone with normal levels of thyroxine and triiodothyronine were unremarkable, the urine screening for drugs was negative, and the cerebral CAT scan showed no alterations (Table , Figures -).\nIn a year follow-up, she still reported no new episodes.
The patient was an 81-year-old man. At the age of 78 years, he noticed postural instability when walking and he occasionally fell down. His gait disturbance and falls gradually grew worse. At the age of 80 years, he visited our hospital due to difficulty with walking. Neurological examinations showed cognitive impairment, parkinsonism, and oculomotor abnormalities. His cognitive impairment included slowing of cognition and frontal release signs. His parkinsonism consisted of masked face, bradykinesia, moderate rigidity of the neck, mild rigidity of both legs, and postural instability. His oculomotor abnormalities were vertical supranuclear palsy, including downward gaze limitation and loss of eye convergence. At this time, his eyes were in the normal middle position. Brain magnetic resonance imaging demonstrated severe atrophy of the midbrain and moderate atrophy of the frontotemporal lobes. Carbidopa-levodopa 300 mg per day was prescribed but was not effective. He was diagnosed with PSP according to the clinical criteria []. Thereafter, he became unable to walk without assistance. At the age of 81 years, he became bedridden due to parkinsonism and had difficulty eating due to dementia and dysphagia. He was admitted to our hospital for gastrostomy. His medical and family histories were unremarkable.\nNeurological examinations again showed cognitive impairment, parkinsonism, and oculomotor abnormalities. The cognitive impairment and parkinsonism had become worse compared to the previous year, and the oculomotor abnormalities included new findings. In addition to vertical gaze palsy and loss of eye convergence, the oculomotor abnormalities included, in his right gaze, adduction paresis of the left eye and rightward nystagmus of the right eye, and, in his left gaze, adduction paresis of the right eye and leftward nystagmus of the left eye. In his forward gaze, his eyes showed alternating extropia: only one eye fixated on the object in front of him and the other eye was abducted. He mainly gazed with his left eye but occasionally used his right eye. The extropia was markedly relieved by Frenzel goggles. His oculocephalic reflex was preserved (Fig. ). The alternating exotropia in his forward gaze and the adduction paresis and outward nystagmus of the abducted eye in his horizontal gaze were compatible with WEBINO syndrome.
The patient, a 76-year-old male, was admitted to our hospital on March 13, 2015 due to recurrent shortness of breath after activities for over 2 years, which became more serious when it manifested with edema of lower limbs 1 day previously. The patient suffered from: coronary heart disease with unstable angina pectoris, triple-vessel disease, and permanent atrial fibrillation, and an extremely risky 3rd degree high blood pressure. With consideration of the possibility of insufficient cardiac functions, the patient was admitted to the Cardiovascular Department for heart failure treatment. Examinations upon admission revealed shortness of breath, thick breath sounds in both lungs, decrease in breath sounds on both bottom sides of the lungs, small number of dry and wet rales, and no pleural friction sounds. The apical pulse moved slightly to the left; the border of cardiac dullness expanded to the left and right, with a heart rate of 120 beats per minute and arrhythmia. In the aortic valve, 3/6-degree diastolic respiratory murmur can be heard in the left armpit, with no pericardial fricative sound. The related examinations were improved after the patient's admission to our hospital. Myocardial markers, cardiac enzymes, and B-type brain natriuretic peptides did not increase. Temporarily, the symptoms were not considered to be caused by cardiac insufficiency. The chest computed tomography (CT) examination revealed that there were pleural effusions on both sides, and some extent of compressive atelectasis in the 2 lower parts of the inflamed lungs, without space-occupying lesions. There were multiple small nodules which were likely benign in the right upper lung, with massive pericardial effusions. Multiple small lymph nodes existed in the mediastinum. There was aortosclerosis and coronary arteriosclerosis. Coronary heart disease has been considered based on the symptoms while the possibility of cardiac insufficiency remained to be removed. The color Doppler ultrasound examination showed a large number of pleural and pericardial effusions on both sides. The thoracentesis of 2 sides and pericardiocentesis were conducted to relieve compressions of the heart and lungs.\nThis patient had a large number of pleural and pericardial effusions with unknown causes. Drainage fluid samples of the thoracic and pericardial cavities were tested severally. With hydrothorax T-SPOT (+), combined with patient's serum T-SPOT (+), there was a great possibility of mycobacterium tuberculosis infection. Abnormal lymphocytes could be found in multiple pathologic examinations of pleural fluid. Therefore, the possibility of a lymphoma was hard to rule out. Through pathology consultations, other experts opined that quite a few abnormal lymphocytes, which were centroblastic and had very visible nuclear fissions, existed in both smears of pleural and pericardial effusions, and cell sediment sections. The immunohistochemistry revealed that LCA and CD20 were positive, whereas CK, CR, CD68, CD3, CD43, CD30, and MPO were negative. With paraffin-embedded cell sections added, the immunohistochemistry manifested that CD20 and EBER in situ hybridization were positive, while CD10, Bcl-6, CD138, and Muml were negative. Morphology and immunohistochemistry of heterogenous cells were consistent with those of large B-cell lymphoid tumors. Thus, based on clinical experience and the positive result of pleural T-SPOT tests, the DLBCL associated with chronic inflammation was considered. To further assess the patient's condition, positron emission tomography (PET)/CT examinations were performed:\nWith more spring-strip-shaped lymphomas at a high metabolism rate below the pericardium, combined with pathology, lymphoma infiltration was likely.\nThere was general cardiac enlargement and wall thickening, pericardial effusions, calcification in multiple coronary arteries, as well as common aortic calcification in the whole body.\nWith pleural effusions on both sides and enlarged lymph nodes in mediastina (4.5 groups), the metabolism was slightly increased.\nInflammatory lymph node hyperplasia happened on both sides of the neck, in axillary regions, and other mediastina.\nThere were nodules in the right upper lobe with no increase in metabolism, which led to a higher consideration of inflamed nodules. On the grounds of the patient's pathology and PET/CT results, the diagnosis supported the hypothesis of PAL.\nHence, 0.3 g qd isoniazid, 1 g qd pyrazinamide, 0.75 g qd ethambutol hydrochloride, and 0.3 g qd rifampicin were used for anti-tuberculosis therapy. In addition, the rituximab with cyclophosphamide, vincristine, and prednisone (R-CVP) chemotherapy regimen was conducted in five rounds. The specific medications were rituximab (500 mg d0), CTX (0.8 g d1), VCR (2 mg d1), and Pred (50 mg d1–5). According to the Response Evaluation Criteria in Solid Tumors (V1.1), complete remission (CR): normal bone marrow phase or histologic examination, complete disappearance of lymph nodes without contact, CT scan of the lesion <1 mm; partial remission (PR): lesion reduction 50%; Stable (SD): lesion reduced by 25% to 49%; progression (PD): reduction of single or several lesions by 24% or occurrence of new lesions. Total effective rate = (CR + PR)/total cases × 100%. Currently a 5-point scale is applied to both clinical trials including interim analysis and end-of-treatment assessment (Table ). During the entire period of treatment, tests including assessment of extra-nodal sites, which initially showed abnormal results were repeated. After treatment, the patient's condition was stable with no adverse reactions. Re-examinations on October 25, 2015, February 15, 2016, and August 10, 2016 revealed no increase in pleural and pericardial effusion.
A 74-year-old man visited our hospital due to diarrhea and melena which had persisted for 4 months. He had undergone left lobectomy with lymph node dissection and received adjuvant chemotherapy for lung cancer 6 months earlier. He experienced an ischemic heart event 3 months before presenting to our hospital and had been taking LDA and clopidogrel ever since. His physical examination revealed anemia in his conjunctiva and skin but no abdominal symptoms. The laboratory data revealed severe anemia but no other abnormalities (Table ). An upper gastrointestinal endoscopy revealed angioectasia in the stomach. However, there was no blood found in the stomach or duodenum. A colonoscopy found no polyps, tumors, or bleeding lesions. Capsule endoscopy (CE) revealed multiple ulcers and erosions in the small intestine (Fig. ). We performed transanal double-balloon endoscopy (DBE), which showed multiple ulcers throughout the ileum with severe ulceration in the terminal ileum (Fig. ). Biopsy specimens were obtained from the ulceration. We diagnosed the patient with non-steroidal anti-inflammatory drug-induced ulceration caused by LDA according to the endoscopic findings. Histological examination revealed cytomegalovirus (CMV) infection in the ileum. To treat the ulcers, he was prescribed misoprostol and continued the LDA. However, 7 days later, he had repeated melena and dizziness due to anemia. We performed DBE again and found that the multiple ulcers in the ileum were obviously exacerbated (Fig. ). We considered this to indicate that the small intestine ulcers were caused by the CMV and the patient was administered ganciclovir (5 mg/kg) for 10 weeks. DBE was performed again 5 weeks after the previous DBE and found that the ulcers had decreased in size, but had not healed. There was no evidence of CMV infection during the histological examination. Therefore, the ulcers were considered to have been due to clopidogrel, which was discontinued. The patient had no subsequent episodes of melena or abdominal symptoms. DBE performed 8 weeks later showed that the small intestine ulcers had completely healed and turned into scars (Fig. ).
A 45-year-old male patient presented to our hospital after a mountain bike accident. He was going downhill and fell on the left shoulder. On clinical examination, the patient had severe pain while testing the active range of motion (ROM) of the shoulder and tingling paresthesia in the left hand with an intact sensitivity. He showed a superficial abrasion over the left shoulder and discomfort to palpation in the middle third of the clavicle. Additionally, the medial clavicle appeared more prominent than the contralateral side and showed vertical instability on palpation. The radiographs showed a minimally displaced midshaft fracture of the left clavicle and a suspected anterior dislocation of the left SC joint (Figure 1). Computed tomography (CT) scans confirmed the diagnosis and showed an anterior SC dislocation without any signs of a neurovascular injury (Figure 1). Initially, the patient was prescribed a sling for immobilization and adequate pain medication.\nAs a thorough review of the literature provided no clear recommendations on the treatment of such injuries, the patient was offered a surgical treatment, due to his age and activity level. Open reduction and plating of the clavicle combined with open reduction and stabilization of the SC joint would allow early mobilization and a better functional outcome. The patient was informed about the operation including possible risks and complications and other treatment options and a written informed consent was obtained.\nThe surgery was performed under general anesthesia in the beach chair position. After cutaneous asepsis of the surgical area, anatomical landmarks were marked using a sterile pen. A 20-cm incision from the SC joint to the transition of the middle to lateral third of the clavicle was performed (Figure 2). The clavipectoral fascia was incised to expose the fracture. The subperiosteal preparation of the clavicle to the medial end showed the SC joint anteriorly and superiorly dislocated with an additional rotation component. After exposing the articular surface of the sternum, the articular disc presented undamaged and was left in situ. The shaft fracture of the clavicle showed a short oblique form and was easy to reduce and, therefore, the decision was made to reduce and stabilize the SC joint first. The medial clavicle could be reduced to the articular surface of the sternum using a reduction forceps with serrated jaws. For a figure-of-8 reconstruction of the SC joint, as described for chronic dislocations, two holes were drilled into the medial clavicle about 10 mm lateral to the articular surface.[] Then, two holes were drilled into the manubrium of the sternum, 8 mm medial to the articular surface. For a stable reconstruction, two 2-mm braided sutures (FiberTape®, Arthrex Inc., FL, USA) were shuttled through the holes in a figure-of-8 pattern and tied. After tightening these first sutures, a slight rotational instability could be observed. To neutralize rotational forces in the SC joint, an additional transosseous suture was placed using a superior drill hole in the medial clavicle 5 mm lateral to the articular surface. These three sutures provided enough stability with joint congruence. Then, the clavicle midshaft fracture was anatomically reduced and a stable fixation was achieved using a 3.5 mm locking plate (3.5 mm LCP Superior Clavicle Plate, Synthes, Inc., PA, USA). Four bicortical locking screws were inserted medially and three laterally to the fracture. Intraoperative X-rays showed anatomical reduction of both the clavicle and the SC joint with ideal positioning of the plate without any protruding screws. Wound closure was performed after thorough irrigation. A shoulder-arm bandage was applied for postoperative immobilization.\nPostoperatively, the patient was admitted to the ward for three days. On the first postoperative day, the patient still reported slight tingling paresthesia in the upright position with resolving in the supine position. A sling was used for six weeks, with physiotherapy with passive swinging motion and continuous passive motion up to 60° abduction starting on the first postoperative day for four weeks. Passive ROM was continuously increased over the next two weeks, followed by active motion and strengthening exercises starting six weeks after surgery. The surgical wound healed without any complications. The patient could return to work (IT consulting) without any limitations after three weeks. At four weeks of follow- up, tingling paresthesia fully resolved and active and passive abduction could be performed up to 60°. The Constant-Murley Score (CMS) showed 35/100 points (39% compared to the unaffected side) (Figure 3) with an apparent decrease in strength and ROM. Shoulder function continuously improved, and fracture healing could be confirmed after eight weeks without any signs of redislocation. Meanwhile, CMS increased to 80% and the patient was not limited in his daily living activities. After 12 weeks, the patient returned to his pre-injury activity level and recreational sports, including mountain biking and hiking. The relative CMS was 93% with unrestricted full ROM in abduction and flexion, and slight remaining decrease in strength and internal rotation. Clinical examination showed a recurring prominence of the medial clavicle without any signs of instability on palpation. Radiographs indicated a 5-mm superior displacement of the medial clavicle (Figure 4) with the midshaft clavicle fracture healed and satisfactory plate positioning. Due to patient’s satisfaction and excellent shoulder function, no further surgical treatment was indicated.
A twenty-two-year-old Iranian woman arrived at our institute with a complaint of severing back pain at the level of T5-T6 vertebrae since two months ago. There was no definite initiating cause and the pain was not associated with the activity. The pain did not radiate into any other part. She did not consume alcohol or illicit drug and had no history of underlying diseases.\nLaboratory data were all within normal ranges except slightly elevated ESR.\nThe radiological study was performed. The Thorax spiral CT scanning without contrast injection was done and demonstrated an expansible bony lesion involving posterior arc of the right 6th rib, costovertebral joint and a portion of the T6 vertebrae. It was measured about 68*44 mm. In MRI, Right D5, D6, and D7 paravertebral mass were seen. The intervertebral foramen was also involved by the enhanced lesion ().\nThen CT-guided biopsy and fine needle aspiration of the lesion was taken. A lobulated and irregular margin without cortical destruction was present. Macroscopic appearance of lesion was suggestive of benign osseous mass but extension into the body and right side of posterior elements of the adjacent vertebra was also seen. The specimen was sent for further evaluations. It contained multiple tiny pieces of brown soft tissue. The histopathologic finding was suggestive of norm cellular bone marrow. There were no malignant or atypical cell ().\nBased on previous cases we decided to perform thoracostomy under general anesthesia by an expert spine surgeon. At the operating room, we performed resection of the proximal parts of right 6th rib and partial T5 and T6 corpectomy. During the surgery, we completely excised the lesion and a safe margin to avoid local recurrence. Intra-operatively frozen section was sent for rapid analysis to determine the safe margin from the lesion in surrounding parenchyma and minimize tissue damage. Although the mass had only involved the rib, and not the surrounding area, we gently removed reactive parts of the cortex for safety. Thus, intraoperative observation also helped in determining the margin of excision to decrease excessive tissue damage.\nThen she was admitted at the Neurosurgery Intensive Care Unit for three days under our close observation. The post-operative period was uneventful. Wound healing occurred without infection or inflammatory response.\nDuring one-year follow-up, she did not experience any abnormality. General physical exams were normal. Laboratory evaluations were all within standard ranges. However, we performed spiral chest and abdominopelvic CT scan; no lesion or any sign of remission was found.\nBased on our review on literature, there were seven similar cases of Focal Hematopoietic hyperplasia reported in articles. Here we also compared our findings with their reports and discussed similar features.
An 20-year-old male presented to the hospital with chief complaints of fever, chills, and shortness of breath. The chest radiograph at admission showed right middle lobe pneumonia with heavy growth of Streptococcus pneumoniae from his sputum without any bacteremia in his blood. On further evaluation, CT scan of the chest revealed right middle lobe and lingular infiltrate with evidence of central bronchiectasis () and CT scan of the sinuses showed severe congestion and inflammation of the frontal, maxillary, and ethmoid sinuses. The pulmonary function test showed predominantly obstruction of the small airways with no improvement after albuterol administration. A marked decrease in the diffusion capacity of the lung with a restrictive pattern was also noted. Further tests were ordered to explore the possibility of a multisystem disease and semen analysis showed a marked absence in motility of the sperm, thereby explaining PCD to be the probable cause of all his symptoms.\nBiopsy of the nasal mucosa was obtained to prove the preliminary diagnosis and to obtain tissue for genetic testing. On electron microscopy of the biopsy specimen most of the cilia present in the epithelial cells of the ciliated epithelium lacked the inner dynein arms and some cilia lacked both dynein arms, thereby confirming the diagnosis of PCD.\nDuring the subsequent visit for followup, the patient complained of worsening of his shortness of breath without any response to medical and respiratory therapy. At this time the patient was also found to have pancytopenia with platelet count of 57,000 cells/cu·mm, WBC count of 4,700 cells/cu·mm, and hemoglobin was 7.2 g/dL. Vitamin B12 and folate levels were normal and no source of infection could be identified after repeated tests and serial scans. Serology for Epstein-Barr virus, HHV1, HHV2, and mumps was negative. The workup for anemia only revealed a low reticulocyte count indicating bone marrow failure being the probable cause of pancytopenia. The patient underwent a bone marrow biopsy to identify the cause of marrow failure in the absence of any infection which revealed high-grade dysplasia and atypical localization of immature precursor cells in the bone marrow clinching the diagnosis of myelodysplastic syndrome (MDS). The bone marrow aspirate was sent for flow cytometry analysis and the results showed deletion of the D7S522 region in the long arm of chromosome 7 (also deletion of D20S108 of chromosome 20 at q12) characteristic of myelodysplastic syndrome or an evolving acute myeloid leukemia. Also observed in flow cytometry was a deletion in the short arm of chromosome 7 at sites 7p14-21, responsible for protein DNAH11, one of the proteins involved in the assembly of the dynein arm. FISH analysis was also done on this patient and was observed to be in concordance with flow cytometry results. Further cytogenetic testing did not reveal the presence of any further mutations. This concurrent presence of two deletions in the same chromosome helped to understand the probable etiology in development of these two distinct rare conditions simultaneously and their presentation in such a short rapid time interval. IPSS-R score was 4, classified as intermediate with a median survival time of 3 years and time for 25% of patients to progress to AML: 3.2. The severity of the disease processes warranted referral to a bone marrow transplant center where he was promptly pretreated with Fludarabine and Busulfan and underwent homologous stem cell transplant from his HLA compatible brother.\nRegular followup at the tertiary care center showed good response of the transplanted bone marrow without any evidence of graft versus host disease (GVHD). He is also regularly followed up by a pulmonologist for management of his PCD.
A 40-year-old male patient came to the hospital emergency after a gunshot lesion in the cervical region. He was conscious, hemodynamically stable, and without signs of active bleeding or cervical spine injuries. Physical examination showed significant edema in the region of the mandibular angle, trismus, restriction of mandibular movements, absence of rhinorrhea or epistaxis, and soft tissue injury compatible with the bullet entrance orifice in the right posterior cervical region without clinical signs of exit bullet orifice.\nComputed tomography showed a comminuted fracture of the coronary and mandibular right ascending branches associated with ipsilateral zygomatic-orbital fracture (Fig. ) and the presence of artifacts compatible with the firearm projectile, suggesting an upward trajectory toward the face (Figs. ,).\nAfter physical and imaging evaluation, vascular surgery and neurosurgery teams opted for conservative treatment. However, the maxillofacial surgery team indicated surgical removal of the bone fragments due to the restrictions of the mandibular movements and removal of the fragments of the projectile due to discomfort and superficialisation in the genic region.\nOn the third day after trauma, under general anesthesia, removal of the bone fragments was initiated by intraoral access in the ascending ramus of the mandible, which evolved intraoperatively with an intense arterial bleeding, incompatible with the surgical procedure. Local compression maneuvers were performed using compresses, attempts to pinch with instruments after local exploration and the use of hemostatics, but they were not enough to contain the bleeding. After failure, it was decided to submit the patient to angiography of the external carotid artery.\nThe examination was performed by percutaneous puncture of the right femoral artery and selective catheterization of the external carotid artery and internal maxillary artery, which verified the presence of an PA (Fig. ) with indication of emergency embolization procedure. Through the catheter, the embolization was performed from the installation of 02 micro-platinum springs until the complete arterial occlusion and consequent end of the blood flow of the PA (Fig. ). The selective angiography of the left internal maxillary artery was then performed in different projections to rule out another possible source of bleeding and the possibility of compensatory revascularization.\nThe patient was transferred and remained under observation for 12 hours in the intensive care unit. A new angiography was performed after 24 hours for control, confirming the complete resolution of the PA. The patient was submitted to a second surgery 72 hours after the hemorrhagic episode when a large part of the bone fragments were removed by intraoral access. Also the palpable and superficial portion of the projectile located in the genic region by infraorbital access was removed.\nThe patient was hemodynamically stable, with no complaints and was discharged after 48 hours, without postoperative bleeding recurrences. He had no more complications after 8 months of follow-up.
The patient, a 30-year-old Tibetan man, was treated in the Lhasa Hospital for right tibiofibular fracture December 2012 (Fig. ). After the swelling subsided, he underwent right tibia fracture intramedullary internal fixation. Two weeks after the operation, the patient was able to walk with double crutches without load, and was able to walk without crutches and with some load 3 months after the operation. However, the patient complained of pain in his right lower extremity, especially when moving downhill or down stairs, and experienced a limping gait and obvious tenderness at the fracture end. Three years after originally presenting at Lhasa Hospital, the patient was experiencing persistent pain in the right lower extremity, and his daily activities were severely affected. Thus, he was re-diagnosed with nonunion of the right tibial fracture after internal fixation (Fig. ). The main causes of the nonunion of the fracture were considered to be the excessively thin intramedullary nails and unstable fixation of the fracture. The operation was repeated with replacement of the crude intramedullary nails and grafting of iliac bone (Fig. ). Three months after the operation, the tibial fracture had failed to heal, and further surgical treatment was performed. The proximal locking screw of the intramedullary nail was removed with an expectation to eliminate the stress shielding effect and to promote fracture healing by increasing the microdynamic force while retaining the static interlocking nail. Five months after the operation, the patient abandoned the crutches and was able to walk with a heavy load. Nevertheless, 2 years after the operation, active pain of the right leg persisted with some tenderness around the fracture, especially when moving downhill or down stairs. August 2018 the patient was admitted to our hospital. Physical examination revealed that two old incision healing scars, approximately 2 cm in length, were present at the proximal and distal ends of the right tibia. The middle section showed a scar from an approximately 10-cm incision; pigmentation was found around the incision and tenderness was experienced around the fracture. Imaging results revealed a nonunion of the right tibial fracture, and the admission diagnosis was nonunion of the right tibial fracture after surgery (Fig. ).\nTwo days after admission, “right tibial locking intramedullary nail removal, open reduction and porous tantalum metal plate fixation” was performed. After removal of intramedullary nails during the operation, nonunion of the tibial fracture was corrected and osteoporosis of the fracture end. Osteosclerosis of the fracture was observed, and the sclerotic bones as well as part of the hyperplastic epiphysis were removed; the marrow was reamed at the fracture to keep the medullary cavity open. The resected osteophytes were implanted into the fracture, followed by fixation with a porous tantalum plate.\nAfter the operation, the affected limbs were fixed with plaster. Ankle joint activity training was initiated on the first day after the operation, and knee joint activity training began 2 weeks after the operation. The patient was able to walk with double crutches without load 4 weeks after the operation and could perform normal activities 12 weeks after the operation without pain in the right limb. However, slight tenderness was still experienced around the fracture. Five months after the surgery, the right tibial fracture had healed, based on imaging examination, and the tenderness around the fracture had disappeared; the patient was able to work normally (Fig. ).
An 80-year-old man was admitted to our hospital for the treatment of a rectal tumor found incidentally by rectal examination. The tumor, about 3 cm in diameter, was located on the right side of the lower rectum 3 cm above the anal verge. The pathological analysis of the biopsy sample revealed that the tumor was a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) indicated that the rectal cancer invaded into the muscularis propria without distant metastases and that lateral pelvic lymph node (LPLN) was not enlarged with a maximum long-axis diameter <3 mm. The most important problem was that the patient had a huge benign prostatic hypertrophy, the size of which was 85 × 80 × 70 mm (Fig. a–c). To achieve complete TME with negative CRM, a hybrid transabdominal-transanal approach for ISR was conducted.\nFirst, vascular division and mobilization of the left colon were performed laparoscopically. The transabdominal approach was continued until the anterior dissection of the rectum became difficult due to a huge prostatic hypertrophy. Next, the circumferential rectal incision and subsequent intersphincteric dissection were performed under direct vision to enable attachment of a single port device (GelPoint Mini; Applied Medical). After closure of the anal orifice, the GelPoint Mini was placed to start the transanal approach. Posterior side of the rectum was first dissected until the transanal approach was connected to the dissection layer made by the transabdominal approach. The dissection procedure was extended to the lateral side. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o’clock positions. At the anterior side, the proper dissection layer cannot be easily identified because of the perineal body and the enlarged prostate. Once the dissection plane between the rectum and the prostate could be identified, it was relatively easy to continue along the same plane. The assistance provided by the laparoscopic approach was useful to determine the appropriate dissection line in the transanal approach.

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